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Intake Inquiry Information
Thank you for inquiring about services with Discovering Balance. To ensure that we are able to accommodate your therapy needs we kindly ask that you complete and return the information below within the next 24 hours. Please feel free to contact the Program Manager, Tiffany Azzinaro with any questions (
tazzinarobalance@gmail.com
or 716-810-2644):
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* Indicates required question
Name (First and Last):
*
Your answer
Parent First and Last name if the patient is a minor:
Your answer
Date of Birth:
*
Your answer
Address:
*
Your answer
Is it ok to leave you messages on your phone
*
Yes
No
Required
Email:
*
Your answer
Phone number:
*
Your answer
Insurance Name, EAP or Self Pay:
*
Your answer
Is your insurance:
*
An employer plan
Medicaid
Child/Family Health Plus
I am unsure
Medisource
Other:
Do you prefer in person, in school or telehealth
*
Your answer
Do you need ASL?
*
Yes
No
How did you hear about Discovering Balance
*
Your answer
Is there a therapist you prefer to work with?
*
Angela Annese, LMHC
Brittany Zucco, LCSW
Jennifer Szopinski, LMSW
Kristin Miller, LMSW
Kathryn Fortunato, LCSWR
Laquisha Craig, LMHC
Rebekka Lipp, LMHC
Vanessa Sandor, LCSW, CASAC
Poorna Sudha Goli, MSW Intern
Tiffany Azzinaro, LCSWR
I have no preference
Required
Schedule (We try and keep appointments consistent for your convenience. What is your preferred appointment date and time i.e. morning, evening, weekend or weekday)
*
Your answer
Treatment concerns:
*
Anxiety
Depression
ADHD
Stress
Trauma
School Concerns
Work Stressors
Self Harm
Relationship Issues
Anger Management
Other:
Required
Comments (Any additional information that would be helpful with scheduling and linking with a provider):
*
Your answer
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