Appointment Request

If this is an emergency, call:

New Client Information - Appointment Request

First Name:

Last Name:

Have you been seen at Balanced Living in the past?

Yes

Primary Phone Number

Email address

Date of Birth

Street Address

City

Zip Code

Member ID

(can be found on the insurance card)

Phone Number for Provider Services / Behavioral Health

Can typically be found on the back of Insurance Card

Name of Primary Holder of this Policy:

Primary Policy Holder's Date of Birth:

Insurance Card Front and Back

Add file

Please upload a file

Driver's License or Picture ID

Add file

Please upload a file

Do you want a Virtual or In Person session?

In Person

Virtual

First Available

Mixed (in person/ virtual)

Preferred Location

Dalton

Hiram

Rome

Virtual

Preferred Day of the Week and Preferred Time of the Day (AM/PM)

Briefly describe your reason for seeking therapy now? (this will help us match you with a therapist).

Your information will be encrypted.