N'Perfect Balance | SimplePractice

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Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Sex at birth

For insurance verification

State

Select the state you live in

Address

Reason for care

Type of therapy requested?

**For Minors, please enter minor as the primary client and parent/legal guardian as contact. **

Individual Therapy Couples Therapy Family Therapy Minor Therapy Sex Therapy Premarital Counseling Supervision Selfcare180 (Business) Other

Administrative

Inquiry reason

Referral source

Enter how you were referred to our services

Insurance EAP Physician Government Agency Hospital Non-Profit Personal Search Engine Other

Billing & Payment

Insurance details

For Military/Tricare, please upload your Military ID front and back. If using EAP, please enter the name of your EAP, Self-Pay, or Insurance in the box below. If you are not using insurance, please upload a blank photo below.

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Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred Appointment Times

Note: Consultations are 15mins in length

Morning (8am-11am) Afternoon (12pm - 5pm) Evening (6pm - 8pm) Weekend No Preference

Preferred modality

**For virtual appointments, please use a bigger device than phone (laptop, chromebook, tablet, iPad, Computer)**

Is there anything that the practitioner needs to know?

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Additional Clinician Preference

You have selected to schedule with your preferred clinician. Please select an alternate clinician below in case your first choice is unavailable. To learn more about each clinician, please visit: https://nperfectbalance.com/our-team

Cetara Davis, LPC Alexis Thomas, MFT Sharon Burgess, MFT Ileana Dolomite, MFTI Sharmaine Horton, MFTI Luciana Heard, MFT (virtual only) Tywana Dulan, MFT Donna Kemp, LPC, NCC, ACS (virtual only) La Tonya Dunn Davis, LMFT (virtual only) (Waitlist) Shana Trimble, LMFT, AS, CST (Waitlist)

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.