Pre-Registration to Become a Client at One of Our Therapy Locations or Telehealth (Individual, Couples, or Family Therapy)
This is an interest form; after you complete and submit this form, then you will be directed to an online scheduling portal where you can request an appointment if you are ready to schedule a time. This form will help us answer your questions, get you a quote regarding cost, and to recommend the right therapist that will fit your needs, budget, and schedule.
Date of Birth
Address (Our Providers Only Have Maryland Licenses So Can Only See Clients Who Reside in Maryland or Who are Physically in Maryland During Treatment)
Street AddressLine 2
State / Province
Postal / Zip Code
How were your referred to us?
Personal Referral from Friend or Family Member
Gottman Referral Network
What kind of Relationship Repair are you seeking?
Self-Repair (Individual Therapy for Personal Development or Mental Health Treatment)
Repair with Your Significant Other (Couples Therapy)
Repair With A Child, Parent, or Family Member (Family Therapy)
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 6-9 pm Monday - Friday
Saturday Hours (THERE IS NO SATURDAY AVAILABILITY FOR NEW CLIENTS AT THIS TIME)
Do you have any preferences for a therapist (male or female, younger therapist with most recent training, therapist with a particular ethnicity or religious background)?
What is your preference - teletherapy or in-person therapy
Videoconference (HIPAA Compliant, Your Therapist Will Send You an Email Invite)
In-Person Therapy In Eldersburg, MD (You will need to select an appointment with Pool Ubillus, Lisa Connell, or Dr. Stephanie Knarr)
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)
$200- 225 per One Hour Session with Dr. Stephanie
$150-$175 per One Hour Session Without Using Insurance (Champ Moultrie, LCPC)
$100 per One Hour Session Without Using Insurance (Pool Ubillus or Lisa Connell)
I want to Use My Insurance Please Get Me a Quote (Add Insurance Information Below)
***Kristen Paul, Domenica Carrese, and Gabbriele Edinger are not accepting new clients at this time
What Insurance Your Primary Insurance Carrier?
CareFirst (Pool, Lisa, Champ, and Stephanie are In-Network)
Anthem BCBS or other BCBS (Pool, Lisa, Champ, and Stephanie are In-Network)
Cigna (Pool, Lisa, Champ, and Stephanie are In-Network)
Kaiser Permanente (Stephanie is In-Network)
United/Optum Health (Pool, Lisa, and Stephanie are In-Network)
Aetna (All Providers Are Out of Network)
Dr. Stephanie and Mr. Champ Moultrie do not accept insurance for couples therapy Are you interested in working with Dr. Stephanie at a fee of $225 per hour or Champ Moultrie at a fee of $175 per hour?
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?
Dr. Stephanie provides intensive one-day or two-day private therapy retreats. These are more effective than traditional weekly therapy. Are you interested in getting more information about a one-day or two-day private intensive therapy retreat with Dr. Stephanie for family therapy, couples therapy, or EMDR trauma therapy?
Are you interested in learning more about the Gottman Art and Science of Love weekend retreat for couples?
Are you interested in learning more about the Safe and Sound Protocol integrated with EMDR therapy for the treatment of Autism Spectrum Disorder, ADHD, PTSD, Chronic Pain, and other Related Disorders?
Should be Empty: