IHG Online Patient Communication Form
www.indianahealthgroup.com
703 Pro-Med Lane
Carmel, IN 46032
317.843.9922 phone
317.581.3918 fax
400 Green Meadows Drive
Greenfield, IN 46140
317.462.8882 phone
317.462.9644 fax
Patient Information
*
Patient First Name
*
Patient Last Name
*
Date Of Birth
Name of person sending this message (if different than the patient named above)
*
Phone number where you can be reached
*
Email Address
Message to your therapist
Please note, this form is to be used to send messages to your therapist (LCSW, PsyD, PhD) only. To send messages to your physician, physician assistant, or advanced practice nurse, you must use the link to RelayHealth from the IHG website.
*
Please select the therapist to whom you wish to send a message.
Jim Brooks, PhD
Jeff Child, LCSW
Vickie Dalton, PsyD
Paul Hartman, LCSW, JD
Beverly Inman-Dunigan, LCSW
Robert Jeffries, PhD
Richard Jones, PhD
Kim Moffett, LCSW
Camille Sexton-Villalta, PhD
Marlene Sharp, LCSW
Gary Nunnally DMin, LCSW
Carol Shoot, LCSW
Greg Sipes, PhD
Laurie Voss, LCSW
Evelyn Walter, LCSW
Other
Your message:
(PLEASE NOTE! This method of communication is only for non-urgent communications with your therapist. Do NOT use this form to schedule, change, or cancel an appointment without confirming it with our office staff in person or on the phone. Your message may not be seen for 1-2 business days).
*
Indicates Response Required