Patient Forms

Important information for you—and us.

Before we meet, please review the practice documents and provide some information about yourself. This will help us get started.

For online enrollment:

Below are the forms that you will need to complete prior to your first appointment. There are several options for this. You can download, complete the forms; or, we can mail you the enrollment packet to complete. Once you have reviewed the forms and your questions are answered, please email the following statement, as a placeholder: 

I consent to the HIPPA policy and the policies provided and have read all the forms.

 

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.


Prior to signing the forms, we will schedule a brief phone call with you to complete enrollment. At that time, we can answer any questions you have about our services or the forms. For your security, please do not provide your social security number or any financial information on the forms. You will provide billing information for secure electronic payments during your enrollment phone call.   

 

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. Please do not provide your social security number or any financial information until we meet. You will complete the billing authorization form in the office. We will also make a copy of your insurance card and ID at your first appointment.  

 

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

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©2019 A Balanced Life LLC

6155 Oak Street Suite B Kansas City, MO 64113

jane@abalancedlifellc.com

Office: (816) 607-3091

Fax: (816) 494-1952

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