Initial Screening for Possible Services

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Please note when you complete this form it is only to give administrative staff an idea if we have a clinician who can meet your wellness needs. This form is used only as a screening tool to see if we accept your insurance, have times available that fit your schedule and have a therapist available with training to provide the supports you need.

PLEASE NOTE WE ARE ON A 4-8 WEEK WAIT AT THIS TIME FOR DAYTIME APPOINTMENTS AND LIMITED AVAILABILITY AFTER 2PM START MID MAY/ EARLY JUNE FOR FIRST TIME APPOINTMENTS.

WE ARE NOT ABLE TO ACCOMODATE MEDICARE OR MEDICAID APPOINTMENTS AT THIS TIME DUE TO CLINICIAN CHANGES

First and Last Name *

How Did You Find Out About LifeBalance? *

If referred by someone, primary care, other counselor etc; who or what agency referred you

Are you willing to see a pre-licensed clinician with 5 years post masters experience. This clinician is working under the supervision of our Clinical Director while completing license requirements. Due to contracts with insurance she is able to accept Anthem insurance or is offering a self pay rate of $100. *

Yes

Maybe

Are you requesting or referred to a specific provider here? (please choose)

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