Appointment Request

Emergency Assistance

If this is an emergency, call:

Georgia Crisis & Access Line (GCAL) 1-800-715-4225
911

New Client Information - Appointment Request

First Name:

Last Name:

Are you a new or returning client?

New

Returning

Primary Phone Number

Do you have immediate family members who are also clients here? Please indicate whether you are aware of family members who also see any of our therapists.

Yes

This helps us to avoid conflict of interest when scheduling.

No, not that I am aware of at this time.

Email address

Date of Birth

Street Address

City

Zip Code

Member ID

As shown on insurance card

Phone Number for Provider Services / Behavioral Health or Mental Health

Typically found on the back of Insurance Card

First & Last Name of Policy Holder for Primary Insurance:

Primary Policy Holder's Date of Birth:

Member ID

As shown on insurance card

Phone Number for Provider Services / Behavioral Health or Mental Health

Typically found on the back of Insurance Card

First & Last Name of Policy Holder for Secondary Insurance:

Primary Policy Holder's Date of Birth:

Insurance Card(s) Front and Back

Add file

Please upload a file

Driver's License or Picture ID

Add file

Please upload a file

Preferred session type?

In Person

Virtual / Telehealth

No Preference

Preferred Location

Dalton

Rome

Virtual / Telehealth

Do you have a preferred therapist in mind?

Please enter the name of your preferred therapist

Do you have a preferred day/time for scheduling?

Please list any scheduling preferences you have

Briefly describe your reason for seeking therapy now?

This helps us to pair you with our therapist who are trained in specific specialties.

Your information will be encrypted.

Appointment Request

Emergency Assistance

New Client Information - Appointment Request

Emergency Assistance

Balanced Living Counseling Center