Pre-Screen Form
The following questions help us to know that we are the best fit for you. Please fill them out honestly and completely.

If you are in crisis please stop and call 911 or the crisis line at 602-222-9444. Inner Balance Counseling is not a crisis center and does not take crisis calls.

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What is your name? *
What is your contact number? *
What is your email address? *
Who is the counseling appointment being made for? Please know you cannot make an appointment for another adult and we only treat clients adults 18 years and older. We DO NOT provide couples/marriage counseling.
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What are you looking to get help with today?
Have you had any thoughts about death, dying or suicide in the last 3 months?
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Have you tried or have you been hospitalized for suicide in the last 6 months?
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Have you been  hospitalized for any psychiatric reasons in the last 6 months?
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Have you ever had a drug or alcohol problem? If yes, please explain.
Adults only: Does anyone have your medical power of attorney or make medical decisions on your behalf?
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Do you have any current legal problems? (e.g. child custody, divorce, substance use treatment requirement, etc.)
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Will you be requiring any paperwork for disability, FMLA or emotional support animals? *Please note all of these things are outside our scope of practice and cannot be ethically provided*
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Have you ever had a domestic violence charge, exhibited violent behavior or thought about hurting other people?
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Have you ever been diagnosed with a traumatic brain injury(TBI)?
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How did you hear about us?
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