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.
Form Validation
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429 E. Vermont Street
Suite 307
Indianapolis, IN 46202

317-572-7847 (ST4R) Call/Text

317-632-3225