Life Balance Counseling and Wellness, LLC

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Guardian name if under 18

Client Preferences

Preferred clinician

Select a clinician from the list

Reason for care

Our therapists provide outpatient counseling, which is best for things like stress, anxiety, depression, relationship challenges, trauma recovery, and life transitions. You can see our clinician profiles on our "About Our Therapists" page to see the specialties of our clinicians. If you’re currently experiencing very severe symptoms, you may need a higher level of care. Does outpatient counseling sound like the right fit for your needs right now?

Yes, outpatient counseling feels right for me I may need more support than outpatient counseling

Type of Session

Are you requesting mental health therapy, sex-related therapy, or couples therapy?

Is working with a specifically queer-affirming/ queer-aligned therapist important for you?

Yes, I want to work with an experienced queer-affirming and aligned therapist No preference

Would you prefer to work with a therapist who understands neurodivergence, such as ADHD or autism, from personal experience or specialized training?

Yes, I prefer a therapist with a neurodivergent perspective No preference

Please tell us briefly what is bringing you to counseling

Once we have your information, we will reach out to you via email. We look forward to working with you!

Limited to 600 characters

Billing & Payment

Primary Insurance

Please choose your insurance type. The insurances listed are those we are in network with. If your insurance is not listed, we are not in-network with it. ***WE ARE NOT PANELED WITH MEDICAID OR MEDICARE***

Primary Insurance ID/ Member Number (write "0000" if not using insurance)

Do you have secondary insurance/ another insurance plan?

If you have another insurance plan, please list it here

If you are using insurance, it is important to understand your portion of the cost-sharing for outpatient therapy for your plan. Are you aware of your copay, coinsurance, and/ or deductible for your plan?

Yes, I know my financial responsibility with my plan. No, I will need help understanding this. Not using insurance

Administrative

How did you find us?

Please let us know how you found our practice.

Referred from a friend or family member Google search/ found your website Psychology Today/ other database Referred from another medical or mental health professional Referred from my insurance Other

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

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.