Inner Balance Mental Health

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Depression OCD Bipolar disorder Insomnia Other

Have you ever been diagnosed with any mental health condition in the past?

Limited to 600 characters

Administrative

Driver's license upload

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

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.