Contact Form

Contact Form

Please do not use this form if you have a psychiatric or medical emergency. Instead, please call 911 or go to the nearest emergency room.
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
State of Residence
Preferred Method of Contact*

PhoneEmail
Are you a current patient of Balanced Mind Mental Health?

YesNo
Please do not include sensitive health information in your message. Do you understand?*

YesNo
Consent to Contact*

YesNo
Message*
Disclaimer:

Please do not include any sensitive or confidential information in this form. For your privacy and protection, we recommend using this form for general inquiries only. If you have a specific questions regarding your health or need to discuss confidential matters, please contact us directly by phone.
Please verify that you are human*
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