Balanced Minds Therapy | SimplePractice

Reason for care

What is your primary reason(s) for seeking therapy services at this time?

Limited to 600 characters

Client Preferences

How will you attend sessions?

In-person Telehealth (online video) No preference

What is your preferred availability? Please note that evening appointments are limited. Select all that apply.

Weekday Morning: 9am-12pm Weekday Afternoon: 12pm-4pm Weekday Evening: 4pm-7pm Weekend

Administrative

Payment method

How do you plan to pay for services?

Please select your health insurance provider (if applicable). Please note that health insurance cannot be used for couples therapy.

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.

Who would be receiving care?

Your info