CONSULTATION FORM

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Client Full Name

Client Date of Birth

Phone Number

Email

Parent's Full Name (if client is a minor)

Preferred method of communication?

Call

Text

Email

Client is currently struggling with (check all that apply):

Anxiety

Depression

PTSD

Hopelessness

Panic attacks

Low self-esteem

Lack of or poor sleep

Inability to focus

Aggressive behavior

Anger/Rage

Suicidal thoughts

Self-harm

Recent trauma

Past trauma

Anything else you would like us to know?

How did you hear about NeuroBalanced?

NeuroBalanced does not accept insurance and is private pay only. Please check the box stating you are aware and accept.

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