Name

First Name

Last Name

Phone *

By providing your phone number, you give consent for Balance Point staff to call and/or send messages to you in regards to your inquiry. We will only use this number to reach back out to you in response to this form.

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Phone - Disclosure *

I agree to receive communications by text message about my inquiry. You may opt-out by replying STOP or reply HELP for more information. Message frequency varies. Message and data rates may apply. You may review our Privacy Policy via the link at the bottom of this form to learn how your data is used.

Yes, I agree

No, I do not agree

Inquiring about: (check all that apply) *

Counseling with Angela Anderson

Counseling with Beth Falb

Counseling with the first available therapist

Opportunities in the community (i.e. speaking, writing, educating, etc.)

Joining the Balance Point team

How did you hear about us? *

Friend or family member

Doctor or provider

Google

School

Insurance company

Employer

Other