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): *
Date of Birth: *
Address: *
Is it ok to leave you messages on your phone *
Required
Email: *
Phone number: *
Insurance Name or Self Pay: *
In person or telehealth *
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) *
Comments (Any additional information that would be helpful with scheduling and linking with a provider): *
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