110 W. Linden Dr, Suite B, Jefferson, WI 53549

phone 920-674-5050

Providing Jefferson & surrounding communities quality mental health therapy

Forms to fill out

Below are most of the forms that will be filled out at your Initial Assessment with Restoring Balance Counseling, LLC in Jefferson, WI.  You are welcome to fill them out and bring them with you when you come in.  If you do not feel comfortable, are unable, or have questions about filling them out prior to your Initial Assessment, no problem!  We will be happy to assist and answer any questions you may have at your first session.


Below are suplemental forms and brochures to review and print to keep you informed of Restoring Balance Counseling, LLC policies, as well as your rights as a consumer of mental health services.  These forms are the items you are initialing for in the FORMS TO FILL OUT section above.  If you are unable to review or print the documents, please ask and we will be happy to provide you with copies.

Child rights brochure (pdf)


Client rights brochure (pdf)


Involuntary discharge policy (pdf)


HIPAA (pdf)


Payment Policy (pdf)