Demographic Questionnaire

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If you want insurance claims field, please complete below:








I authorize the release of treatment data, including drug and alcohol information, if required by my insurance. I also authorize all behavioral health benefits payable under my insurance policy to Matthew G. Grant, Psy.D., HSPP-NorthStar Psychological + Consultation Services, LLC so that they may be applied to my account. The remainder left unpaid is my responsibility unless otherwise stated.
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NorthStar Psychological + Consultation Services, LLC
429 E. Vermont Street
Suite 307
Indianapolis, IN 46202
Phone:
317-572-7847 (ST4R)
Fax:
317-632-3253
eMail:
info@northstarpsych.com
Hours:
Monday 3:00 pm to 8:00 pm & Tuesday through Thursday 8:00 a.m. to 8:00 p.m. Closed all other days.