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Therapy Referral Form

Let's Get You Connected

Taking the first step toward support should be simple. Complete the referral form below and our team will guide you through the next steps.

Online counselling

Who We Serve

Adolescents, adults, couples and families.

Insurance & Payment

We accept Anthem, Caresource, United Healthcare, HIP, Medicaid, Medicare and more. Private pay options are also available.

What to Expect

Within 24-48 business hours you will receive an email with instructions to access our patient portal and complete intake and consent forms. After forms are completed, please allow an additional 24-48 business hours for our team to verify insurance and connect you with a therapist.

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Please watch your email for follow up communication from us!

If this is an emergency

If you or someone else is in immediate danger, please call 911  or go to the nearest emergency room. This form is not monitored 24/7 and should not be used for urgent or crisis situations.

Where to Receive Care

In Person

Downtown Indianapolis, Brownsburg & Noblesville

Virtual Therapy

Available throughout Indiana for ages 15+

Finding the Right Therapist

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You don't have to know who you need.

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Tell us what you're looking for and we'll help connect you with a therapist based on your needs, preferences and availability.

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Helping People Discover the Best Version of Themselves

Therapy Referral Form

Please complete the information below to refer a client to Collaborative Change. All information is confidential.

Before You Begin

Collaborative Change provides therapy services for individuals 10 and older. Please complete this form to help us understand your needs and availability.


Please note: We do not currently accept Cigna or TRICARE insurance.

Client Date of Birth
Month
Day
Year
Is the client under the age of 18?
Yes
No
Preferred Service Location
Preferred Days for Therapy
Preferred Times for Therapy
What would you like support with?
Do you have a therapist preference?
Help me find the right fit
First available therapist
I would like to request a specific therapist
I have another preference
How will you be paying for therapy?
I will be using insurance
I will be self-pay/not using insurance
How did you hear about Collaborative Change?
Friend or Family
Current or Former Client
School
Healthcare Provider
Google/Online Search
Social Media
Other

What Happens Next?

After you submit your referral, we'll email you within 24-48 business hours with instructions to access your patient portal and complete your intake and consent forms.


Once your forms are completed, please allow another 24-48 business hours for us to verify your insurance benefits (if applicable), review your needs and availability and connect you with a therapist.


Please watch your email, including your spam or junk folder for messages from Collaborative Change.


This form is not monitored for emergencies or immediate crisis needs. If you are experiencing an emergency, call 911 or go to the nearest emergency department.

BEFORE YOUR FIRST APPOINTMENT

Complete Your Forms

All intake and consent forms must be completed before we can move forward

Insurance & Payment

We'll verify benefits and explain any expected fees before services begin.

Watch Your Email

Most communication during the intake process happens by email.

Meet Your Therapist

Once everything is complete, we'll connect you with a therapist based on your needs and current availability.

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