Demographic Questionnaire
If you want insurance claims filed, 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. Even if you're using your EAP benefits, you still must complete the entire form.
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Indianapolis, IN 46202

317-572-7847 (ST4R) Call/Text


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