Request an Appointment

Emergency Assistance

Please do not use this form if you need immediate assistance. If you are having a mental health emergency, call:

National Crisis Line: 988 (call or text)
911
Visit your local emergency room

Client Information

First name

Last name

Email address *Please make sure address is accurate. This is how we respond to you.

Phone number

I'm already a client

Days and times you are available

Which days of the week are best for you?

We offer weekday appointments only.

Time of day that works best

Evening appointments are available but we can often get you scheduled sooner if you can schedule before 3pm.

About Your Appointment

Insurance information

Please tell us what type of insurance you have if you plan to use your insurance benefits. We can let you know if we are paneled with your insurance company. Type in "cash" if you will be self-pay. (We are not paneled with Medicaid, Hoosier Healthwise, or HIP.)

What brings you to counseling?

Please tell what issues or symptoms you are experiencing. If this is for a child please tell us the child's name and issues being presented.

Please give the full birthdate of the potential client

Email address

Your information will be encrypted.

Request an Appointment

Emergency Assistance

Client Information

Days and times you are available

About Your Appointment

Emergency Assistance

Harcourt Counseling Services