Patient Forms

Important information for you—and us.

For online enrollment:

If you have completed your brief enrollment phone call, please download and complete the forms below prior to your first appointment. For your security, do not provide your social security number or any financial information on the forms. Then, email the following statement, as a placeholder: "I consent to the HIPPA policy and the policies provided and have read all the forms." (Please let us know if you would like us to mail you the forms instead.)

 

Next, return the new client information form and the signature page of the other forms to A Balanced Life LLC by email, fax, or mail including a copy of your ID and the front and back of your insurance card. Lastly, please provide your insurance information in our secure New Patient PortalThis will allow us to set up insurance claim filing for you.   

 

Where to send your completed forms:

Fax: 1-816-494-1952
Email: jane@abalancedlifellc.com
Mail: A Balanced Life LLC
   6155 Oak Street STE B
   Kansas City, MO 64113

For in-person enrollment:

Below are the forms you will complete at the beginning of your appointment. The only form we request you to complete and bring with you is the new client information form. The others are for your review so that all your questions can be answered before signing them in the office. Do not provide your social security number or any financial information until we meet. You will complete the billing authorization form in the office. Please provide your insurance information in our secure New Patient PortalThis will allow us to set up insurance claim filing for you.   

 

You will receive either an email or text reminder of your appointment 48 hours in advance. 

 

We look forward to your visit.

Informed Consent for Psychotherapy and Practice Policies

Informed Consent for Telehealth During the Coronavirus (Covid-19) Pandemic

New Client Information Form

(Please complete and bring to visit.)

Payment, Patient Balance, and Credit Card Policies 

Notice of Privacy Practices

(HIPAA)

Authorization for Electronic Communication