Appointment Request

New Client Information

Please correct the errors described below.

New Client Information - Appointment Request

We will always be discreet and only leave a message for you to call us back.
If you do not see your insurance company, please select other and please note that Balanced Living does not accept Medicaid or Medicare.
As shown on insurance card
Typically found on the back of Insurance Card
    Please upload a file
      Please upload a file
      Please enter the name of your preferred therapist

      Your information will be encrypted.