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FORMS



If you have scheduled an intake at Balance Behavioral Health, then you might want to save time at your initial appointment by completing forms prior to your visit. Please print out the appropriate forms and complete at home. Then you can email these forms to us at administrator@balancebehavioral.com or bring these forms with you to your initial appointment and give them to the front office staff.

You will need to complete the Tele-Health Consent Form, the Patient Registration Form, one of the questionnaires, and the HIPPA Signature Form for your initial appointment or if you haven't been seen for more than a year. If you haven't completed the Tele-Health Consent Form previously, please sign it and email it to us. You will also need to sign a cancellation and court policy form before your first appointment.

Don't forget to bring your insurance card and copay to your initial appointment. You may want to contact your insurance company before your appointment to verify coverage and find out about your deductible and/or copay.

NOTE: Please see the "Psychiatry Appointments" page for the paperwork you will need to complete before your appointment with our Psychiatric Nurse Practitioner, Tim Walsh.



Tele-Health Consent Form



Cancellation Policy and Court Fees Form



Patient Registration Form (must be completed BEFORE Intake Session!)



Adult Questionnaire (ages 18+)



Adolescent Questionnaire (ages 13 to 18)



Child Questionnaire (ages 1 to 12)



Marital/Couple Questionnaire (both partners complete before intake)



Family Questionnaire



HIPAA Signature Form (must be signed BEFORE Intake Session!)



HIPAA Notice and Patient Information



Patient Update Information Form (complete if you haven't had a session at our office in 6+ months)



Balance Behavioral Health, PLLC



6504 Woodlake Village Circle
Midlothian, VA 23112
PH: 804-823-5475
FAX: 804-818-3644
administrator@balancebehavioral.com


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