Level of Care *

Our therapists provide outpatient counseling, which is best for things like stress, anxiety, depression, relationship challenges, trauma recovery, and life transitions. You can see our clinician profiles on our "About Our Therapists" page to see the specialties of our clinicians. If you’re currently experiencing very severe symptoms, you may need a higher level of care. Does outpatient counseling sound like the right fit for your needs right now?

Yes, outpatient counseling feels right for me

I may need more support than outpatient counseling

Type of Session *

I am interested in on-line sessions and acknowledge that I will need to be in the state of PA for my online video sessions.

I am only interested in in-person sessions.

I can do in-person or online sessions.

Are you requesting individual mental health therapy or individual sex-related therapy? *

Individual Mental Health Therapy

Individual sex-related therapy (current waitlist)

Is working with a specifically queer-affirming/ queer-aligned therapist important for you? *

Yes, I want to work with an experienced queer-affirming and aligned therapist

No preference

Would you prefer to work with a therapist who understands neurodivergence, such as ADHD or autism, from personal experience or specialized training? *

Yes, I prefer a therapist with a neurodivergent perspective

No preference

Legal Client Name *

First Name

Last Name

Phone

(###)

###

####

Do you have secondary insurance/ another insurance plan? *

YES

NO

Not using insurance

* Regarding Insurance* *

If you are using insurance, it is important to understand your portion of the cost-sharing for outpatient therapy for your plan. Are you aware of your copay, coinsurance, and/ or deductible for your plan?

Yes, I know my financial responsibility with my plan.

No, I will need help understanding this.

Not using insurance

How did you find us?

Please let us know how you found our practice.

Referred from a friend or family member

Google search/ found your website

Psychology Today/ other database

Referred from another medical or mental health professional

Referred from my insurance

Other

Life Balance is not in-network with any form of Medicaid including those provided by commercial insurance companies (e.g. UPMC for You). *

I acknowledge

Life Balance requires that clients be in treatment with our therapists for at least 3 months of consistent appointments before any forms or letters will be provided. *

I acknowledge

Life Balance does not accept insurance for couples sessions. These sessions are private pay only. Information can be found on our Rates and Insurance page.

I acknowledge