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  • Therapy Interest Form

    Please note that this form shall not be interpreted as entering you into a therapeutic relationship with Balanced Mind Therapy. This is an initial form to gather your basic information in order to determine if Balanced Mind Therapy is the best fit for your needs and goals.
  • IF YOU ARE FEELING SUICIDAL OR ARE HAVING ANY THOUGHTS OF HURTING YOURSELF, OR COMMITTING SUICIDE, DO NOT SEND A MESSAGE ON THIS FORM. PLEASE IMMEDIATELY CALL 911, GET YOURSELF TO THE NEAREST EMERGENCY ROOM, OR CALL THE NATIONAL SUICIDE PREVENTION LIFELINE AT 1-800-273-8255.

  • Therapy Preferences:

  • Goals and Expectations:

  • Should be Empty: