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Serving Indiana clients via teletherapy
Office hours: Tuesday – Friday 1pm to 6pm
Note: This is not an emergency service
Call 911 for emergencies, or 988 for suicide prevention services

New Client Appointment Request Form

Full Name*

Email*

Phone*

Street Address*

Zip Code*

I Request Therapy: *

As an Individual As a Couple

Partner's Name (if applicable)

Partner's Email

Best way to contact you

Phone Email

Briefly, please describe what you would like to focus on in therapy

I understand that ordinary email and text are not secure forms of communication. I accept the risk this may pose to my protected information (SSI, bank info, etc.), and so will keep exchange of any protected information to a minimum. I consent to allow Relational Therapy Indy LLC to communicate with me via email or text.

Relational Therapy Indy

Schedule Your Appointment

New Client Appointment Request Form

Relational Therapy Indy

Dennis Daupert, PhD, HSPP