New Patient Request | Balanced Mental Health of Arizona

Please do not use this form if you have an urgent medical problem, need to reschedule an existing appointment, or are a current patient wishing to schedule a new appointment. Existing patients may use our Patient Portal or call our office at (623) 349-1711 for further assistance. After you submit your new patient appointment request, our scheduler will respond within 48 hours.

Appointment Request

Contact Information

First Name * Last Name * Date of Birth * Street Address * City * State * ZIP Code * Phone Number * Email Address *

Appointment Details Reason For Appointment * Insurance Carrier, Member ID and Group Number *

Please Note: At this time we are unable to accept any AHCCCS plans.

Preferred Days and/or Times for Appointment * Referred By *

Please Note: Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.

* = Input is required