Type of Session *

I am interested in on-line sessions and acknowledge that I will need to be in the state of PA for my online video sessions.

I am only interested in in-person sessions.

I can do in-person or online sessions.

Are you requesting individual or couples counseling? *

Individual Sessions

Couples Sessions, which are private pay only at Life Balance

Legal Client Name *

First Name

Last Name

Phone

(###)

###

####

Do you have secondary insurance/ another insurance plan? *

YES

NO

Not using insurance

* Regarding Insurance* *

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

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

Life Balance is not in-network with ANY form of Medicaid/Medicare, including those provided by commercial insurance companies (e.g. Aetna, UPMC). *

I acknowledge

Life Balance requires that clients be in treatment with our therapists for at least 3 months of consistent appointments before any forms or letters will be provided. *

I acknowledge

Life Balance does not accept insurance for couples sessions. These sessions are private pay only. Information can be found on our Rates and Insurance page.

I acknowledge