Request appointment | Inner Balance Counseling

Request an appointment

Referral source

Enter how you were referred to our services, or how you heard about us.

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Would you like to receive text message reminders about your appointments, scheduling updates, or other important information from our practice? We will never share or sell your phone number, and you won’t receive any spam messages.

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Have you ever had a drug or alcohol problem? If yes, please explain.

Limited to 600 characters

Do you have any current legal problems? If yes, please explain.

(e.g. child custody, divorce, substance use treatment requirement, etc.)

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If applicable, do you anticipate requesting documentation from your provider for legal purposes? If yes, please explain.

(e.g., to present in court or support your case)

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Have you ever had a domestic violence charge? If yes, please explain.

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Do you have someone who usually makes medical or legal decisions for you, even when you are awake and alert?

(This does not include a Health Care Power of Attorney that only applies if you are unconscious.)

Limited to 600 characters

Inner Balance Counseling does not provide letters or paperwork for: FMLA, Disability, Emotional Support Animals and Legal evaluations or recommendations. We can provide documentation of treatment dates or send your records. Do you understand and agree to this?

Yes

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.