Healing & Balance LLC | SimplePractice

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

You are welcome to share your pronouns

Reason for care

What type of services are you interested in receiving?

Reminder, all session are VIRTUAL at this time and for adults only.

Psychotherapy / Mental Health (WI residents only) Somatic Experiencing SE Student Personal Session SE Student Consultation Integrative Somatic Wellness Session Professional Consultation Services Other

What is the reason that you are seeking care?

Support mental and emotional health Support overall wellbeing Address trauma recovery Address physical health issue Professional Development / Consultation Somatic Experiencing Student Unsure or other reason

What mental health concerns or treatment have occurred in the past?

If you are not seeking mental health care, you can select NONE.

In psychotherapy treatment now Attended psychotherapy sessions in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now, or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past Substance Abuse treatment in the past Easting Disorder treatment in the past NONE of these apply, or not seeking mental health care

Administrative

Questions you have regarding your contact request:

Questions about therapy costs Out of Network Insurance questions Ready to schedule my first appointment Check therapist availability Request a free consultation call Questions about treatment approaches or specialties Requesting consideration for sliding scale fee Other

Referral source

Please share how you were referred to our services:

Client Preferences

Preferred appointment times

TUES - AM TUES - PM WED - AM WED - PM THURS - AM THURS - PM FRI - AM FRI - PM other time not listed

What frequency of appointments are you interested in?

(weekly appointments are not available)

bi-weekly once a month every 4-6 weekls

Please share brief information regarding what you want to address in sessions together, and how I can best support you if we are able to work together.

(Please note: If you are having a health or mental health emergency, this is not the appropriate format to receive urgent support. Please seek services locally and in person from trusted providers).

Limited to 600 characters

Is there anything else that you would like the practitioner to know about your request?

Limited to 600 characters

I acknowledge that Healing & Balance LLC is currently offering virtual sessions for adults only. I also acknowledge that Healing & Balance LLC is not affiliated with any insurance companies and sessions provided are fee for service and paid the day of service. Psychotherapy services in WI may be eligible for partial reimbursement through out of network billing, if you submit your receipts to your insurance company (not available for Medicare/Medicaid). Most sessions are eligible for reimbursement through HSA/FSA accounts.

Yes

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.