Intake Inquiry Information
Thank you for inquiring about services with Discovering Balance. To ensure that we are able to accommodate your therapy needs we kindly ask that you complete and return the information below within the next 24 hours. Please feel free to contact the Program Manager, Tiffany Azzinaro with any questions (tazzinarobalance@gmail.com or 716-810-2644) :
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Name (First and Last): *
Parent First and Last name if the patient is a minor:
Date of Birth: *
Address: *
Email: *
Phone number: *
Is it ok to leave you messages  on your phone *
Required
Insurance Name, EAP or Self Pay (Unfortunately, The only form of Medicaid we accept at this time is Fidelis): *
Do you have secondary insurance *
Do you prefer in person, telehealth or both *
Do you need ASL? *
How did you hear about Discovering Balance *
Is there a therapist you prefer to work with? *
Required
Schedule (We try and keep appointments consistent for your convenience. What is your preferred appointment date and time i.e. morning, evening, weekend or weekday) *
Treatment concerns: *
Required
Comments (Any additional information that would be helpful with scheduling and linking with a provider): *
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