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Complete the form below and we'll get back to you as soon as possible!

If you are completing this form on behalf of an adolescent, please enter the adolescent’s information as the primary information on the form. In the Additional Information section, please provide the full name and date of birth of the adolescent’s primary parent or legal guardian.

Insurance Verification

Ready to get the ball rolling! Upload the needed documents to have your insurance verified. If you don't have insurance, we will get back to you with information about private pay rates.

Front of Insurance Card
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Driver's License
Upload supported file (Max 15MB)
Back of Insurance Card
Upload supported file (Max 15MB)

By signing below, I hereby grant BLISS Counseling & Consulting permission to contact me about my inquiry, create a client portal if I choose to move forward, and/or utilize the information listed above to verify my health insurance benefits.

The information provided will be used solely for the purpose of tracking the number of clients who are Tuskegee University (TU) students. No personal information will be shared, sold, or disclosed to any third party. We are committed to protecting your privacy and ensuring that your data remains confidential.

Once submitted, allow the page to process. Don't double submit.

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If you have any issues submitting the form, please reach out to us directly at admin@balancelifecounseling.com. 

Email is the best form of contact. Please provide your name, address, driver's license insurance card, and reasons for seeking therapy to get the ball rolling!

By submitting this form, you consent to receive communications from BLISS Counseling & Consulting, LLC, including information about services, programs, events, educational resources, practice updates, and promotional or marketing communications. You may opt out of marketing communications at any time by following the unsubscribe instructions provided or contacting our office. Opting out of marketing communications will not affect your ability to receive services or necessary communications related to your care.

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Please note: This form is not monitored for emergencies and should not be used to request immediate or crisis assistance. If you are experiencing a medical or mental health emergency, are in immediate danger, or believe you may harm yourself or someone else, call 911 or go to the nearest emergency department. For suicide or mental health crisis support in the United States, call or text 988 to reach the Suicide & Crisis Lifeline.

Address

2232 Victory LN Ste 900

Hoover, AL 35216

Phone

205 - 552 - 2370

Email

admin@balancelifecounseling.com

Crisis & Emergency Notice

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BLISS Counseling & Consulting, LLC does not provide emergency or crisis response services through this website, and website forms and messages are not continuously monitored.

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If you are experiencing a medical or mental health emergency, are in immediate danger, or believe you may harm yourself or someone else, call 911 or go to the nearest emergency department.

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For suicide or mental health crisis support in the United States, call or text 988 to reach the Suicide & Crisis Lifeline.

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