Registration to Become a Client at One of Our Therapy Locations - We Provide Individual, Couples, and Family Therapy
If you are an existing client, you may scroll all the way down to the bottom of the page and click submit and you will be directed to the online scheduler to select your next appointment. If you are a new client, after you complete and submit this form, then you will be directed to an online scheduling portal where you can request an appointment for individual, couples, or family therapy. This form will help us answer your questions, get you a quote regarding cost, and help us to recommend the right therapist that will fit your needs, budget, and schedule. At this time, Dr. Stephanie only accepts a limited number of new clients, however keep in mind that she supervises her therapist associates and you will still have the benefit of her expertise no matter which therapist you work with. You will be contacted within 24-48 hours of submitting this form to assist you with your first appointment!
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Are you seeking couples therapy, family therapy, or individual therapy and what problems and/or symptoms are you seeking therapy for? Also, are you looking for any particular therapist (male or female, more experienced, younger therapist with most recent training, therapist with a particular ethnicity or religious background)???
When are you usually available to attend appointments? (Dr. Stephanie only accepts new clients during business hours so if you only want to work with her, please select Business Hours or Very Flexible Schedule)
Very Flexible Schedule (I am more concerned about the right therapist at the right cost than I am about schedule)
During Business Hours 9-4pm Monday - Friday
Mostly Late Afternoon Hours 4-6 pm Monday - Friday
Evening Hours Weekdays 6-9 pm
Saturday Morning or Afternoon
Sunday Afternoons or Evenings
Which Location or Locations Are You Interested in? (All locations have some evening or weekend hours available for clients who need after work hours)
Videoconference (HIPAA Compliant, Your Therapist Will Send You an Email Invite)
Laurel Location (Most therapists work at this location on various days of the week)
Maple Lawn Location (Rolonda Williams)
Upper Marlboro Location (Tristin Malone and Tyra Berger )
Owings Mills Location (Chana Johnson on Saturdays, Mondays, Wednesday, and Fridays)
Annapolis Location (Gail Bowles on Wednesdays through Saturdays)
What therapy fee will fit your budget? (Fees are based on the level of licensure and number of years experience the therapist has - These Fees Here Are Without Health Insurance - if you would like to get a quote using Health Insurance Please Indicate Below)
I Want to Use My Health Insurance, Please Get Me A Quote
$10-60 (Sliding Fee Scale to See One of Dr. Stephanie's Interns - Without Using Any Health Insurance)
$100 - $120 per One Hour Session Without Using Insurance (Rolonda Williams, Darrius Humphrey, Krista Zerby, Chana Johnson, Gail Bowles, Tyra Berger, Sophia Rizvi)
$150 - $200 per One Hour Session (Terrie Tyrie and Tristin Malone)
$225 per One Hour Session or $335 per 90 Minutes (Dr. Stephanie)
If you selected the Sliding Fee Scale Above (Not Using Insurance), What amount is consistent with your household income and what you can pay?
$15,000 - $25,000 household income = $10 Cost Per 60 Minute Session
$25,000 - $35,00 household income = $20 Cost Per 60 Minute Session
$35,000 - $45,000 household income = $30 Cost Per 60 Minute Session
$45,000 - $55,000 household income $40 Cost Per 60 Minute Session
$55,000 - $65,000 household income = $60 Cost Per 60 Minute Session
If you would like to find out about health insurance coverage, please put your health insurance type and Member ID # and Date of Birth below. You will get a quote back from our office.
Are there any questions you would like answered when we respond to you? (You can view the answers to Frequently Asked Questions on our website at www.drstephanieonline.com) Do you prefer a response via email or by phone? Any certain hours that will work best for one of our Repair Associates to call you back?
Do you understand that appointments not cancelled 24 hours in advance will be charged the full fee of the appointment to the card on file? You must put your credit card on file either now or when you book your first appointment to hold your appointment. If you would like to enter it now via this confidential, HIPPA compliant, secure method, please enter 16 digit card #, expiration date, and 3 or 4 digit security code here. You will be directed to an online scheduling portal as soon as you complete this form
If you are interested in working with Dr. Stephanie for couples therapy or family therapy, are you able to self-pay at $225. Dr. Stephanie does not accept insurance for any new couples therapy clients.
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