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 ( 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: *
Is it ok to leave you messages  on your phone *
Email: *
Phone number: *
Insurance Name, EAP or Self Pay: *
Is your insurance: *
Do you prefer in person, in school or telehealth *
Do you need ASL? *
How did you hear about Discovering Balance *
Is there a therapist you prefer to work with? *
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: *
Comments (Any additional information that would be helpful with scheduling and linking with a provider): *
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