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.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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. You also agree not to submit any payment information, including credit or debit card details, through this form.