If you are interested in enrollment or would just like more information, please fill out the following form or contact us at 317-849-5437.

If you would like for us to seek authorization of coverage, please include your necessary insurance information. Please note that authorization can take several weeks to process and all information is keep private in accordance with Federal HIPAA guidelines.

Enrollment
*Must be completed in order to submit authorization for insurance coverage

*All Personal Information is kept confidential according to HIPAA federal guidelines

Type of Service:
Diagnosis:
Address:
Questions/Information:
Your Name*:
Email:
Phone Number:
Child's Name*:
Insurance ID Number*:
Three Simple Steps:
Contact us with questions concerning our program

Discuss Funding sources and set up a tour

Complete an initial assessment and program enrollment process

Enrollment Form
Child's Date of Birth*:
Insurance Provider Phone Number*:
(Found on back of Insurance Card)