Child Information

To improve the quality of care for patients, as well as communication between the provider and our clinic, we now require a Provider Information Form from a physician, psychologist, or other mental health provider for all new patients at the Riley Hospital Child and Adolescent Psychiatry Clinic and the Christian Sarkine Autism Treatment Center.

Our Provider Information Form can be downloaded and then completed via computer entry or handwritten format. The completed form should be faxed to our clinic at:


We also require the submission of a completed Patient Information Form before scheduling the patient. This 4-page form, to be completed by the patient's caregiver, is required in addition to the Provider Information Form to ensure that we have adequate information for scheduling. Patients may fax or mail the completed form separately from the Provider Information Form.

We apologize that we are unable to provide electronic submission because of patient confidentiality requirements.

Our intake coordinator will contact the family directly to schedule the appointment.

Please call our office at 317-944-8162, Option #2 if you have any questions. We are available by telephone Monday through Friday 8:00a.m.-5:00p.m.

Riley Child and Adolescent Psychiatry Center and Christian Sarkine Autism Treatment Center

Provider Information Form

Patient Information Form

Department of Psychiatry | 355 W. 16th St., Suite 4800 | Indianapolis, IN 46202 | Ph: (317) 963-7288 | Fax: (317) 963-7313