Balanced Life Counseling, LLC
Forms & Directions
FORMS
Please print and complete the following forms by clicking on your therapist. Bring these with you to your first session. A description of each form can be found below.
*If you are coming as a couple, please print and complete an extra 'Intake Form'.
All Forms in a Single Document
Maike Wegner-Kleine - Adult
Maike Wegner-Kleine - Child / Adolescent
Shelly L. Peed - Adult
Shelly L. Peed - Child / Adolescent
Allen Young - Adult / Adolescent
Intake Form
This form provides us with important information about the client. If a couple is being seen, please have each adult complete the form.
Maike Wegner-Kleine - Adult
Maike Wegner-Kleine - Child / Adolescent
Shelly L. Peed - Adult
Shelly L. Peed - Child / Adolescent
Allen Young - Adult / Adolescent
Insurance Form
Accurate completion of this form will ensure proper billing to your insurance agency.
HIPAA Privacy Notice
This form provides you with important information about your rights as a client in regards to the HIPAA Privacy Notice.
Counseling Agreement
This form provides information about what to expect in therapy, confidentiality, and the overall operation of my services. If you have questions about this information, you may discuss them during your appointment. It is important that both adults in a couple and both parents of a child sign this form. Signing of this form indicates consent for participation in therapy and an agreement to the policies and procedures of the therapist.
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Click here to download the latest version.
Balanced Life Counseling
Balanced Life Counseling
4305 South Lee Street
Suite 400
Buford, GA 30518
Please print and complete the following forms by clicking on your therapist. Bring these with you to your first session. A description of each form can be found below.
*If you are coming as a couple, please print and complete an extra 'Intake Form'.
All Forms in a Single Document
Maike Wegner-Kleine - Adult
Maike Wegner-Kleine - Child / Adolescent
Shelly L. Peed - Adult
Shelly L. Peed - Child / Adolescent
Allen Young - Adult / Adolescent
Intake Form
This form provides us with important information about the client. If a couple is being seen, please have each adult complete the form.
Maike Wegner-Kleine - Adult
Maike Wegner-Kleine - Child / Adolescent
Shelly L. Peed - Adult
Shelly L. Peed - Child / Adolescent
Allen Young - Adult / Adolescent
Insurance Form
Accurate completion of this form will ensure proper billing to your insurance agency.
HIPAA Privacy Notice
This form provides you with important information about your rights as a client in regards to the HIPAA Privacy Notice.
Counseling Agreement
This form provides information about what to expect in therapy, confidentiality, and the overall operation of my services. If you have questions about this information, you may discuss them during your appointment. It is important that both adults in a couple and both parents of a child sign this form. Signing of this form indicates consent for participation in therapy and an agreement to the policies and procedures of the therapist.
Adobe Reader is required to view online forms.
Click here to download the latest version.
DIRECTIONS
Click on address for directions.
Balanced Life Counseling4305 South Lee Street
Suite 400
Suite 400
Buford, GA 30518
Balanced Life Counseling
4305 South Lee Street
Suite 400
Buford, GA 30518