Name of Client *

First Name

Last Name

Client's Date of Birth *

MM

DD

YYYY

Phone Number *

(###)

###

####

The client must be in the state of MA at the time of session in order to proceed with the appointment *

I have read and agree to the above statement

I understand that Discovering Balance will not bill my insurance directly, thus I will be responsible for the cost of my sessions. *

I have read and agree to the above statement

This request for services does NOT guarantee an appointment, nor does it constitute a clinical relationship with Dr. Patrick or Discovering Balance *

I have read and agree to the above statement

Terms: *

Please review the Privacy Policy found on this website. The information you send through this form, and subsequent email communications, will be stored safely and protected in accordance with HIPAA. While unlikely, internet communication does carry some risks. If you prefer, you may call the office and leave a detailed message with the above information. By clicking "Send", you have read and agree to the Privacy Policy

I have read and agree to the above terms