Registration to Become a Client at One of Our Relationship Repair Shop Locations
If you are an existing client, you may scroll down 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 to recommend the right therapist that will fit your needs, budget, and schedule. Although Dr. Stephanie has the most therapy expertise, 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 to assist you with your first appointment!
Name
First Name
Last Name
Email
example@example.com
Phone Number
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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?
Are you interested in working with a particular therapist or attending appointments at a certain location? Or would you like a recommendation based upon who will best meet your needs for clinical expertise, budget, and scheduling requirements? (You can review therapist associates and their schedules, locations, and fees at www.drstephanieonline.com)
Are you planning to self-pay? Or would you like to try to use your health insurance? You may use a health savings card or FSA card, credit card, cash, or check to pay for any co-pays or fees. 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. If you do not have health insurance, the fees for therapy appointments are $60-$200 depending upon which therapist you work with. Is there a certain amount you feel is within your budget for appointments (Fees and insurance information is available on our website at www.drstephanieonline.com)
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?
When are you available to attend appointments? Do you have flexibility to attend regular appointments during business hours 9 am -5 pm. If you are only able and willing to attend appointments during evening or weekend hours please indicate if there are any evenings, Saturdays, or Sundays that are preferred. At this time, Dr. Stephanie is primarily only accepting new clients who can attend daytime appointments during business hours.
Dr. Stephanie is motivated to show people the benefits of different types of therapy through video posts on her you tube channel. Of course, some clients are not comfortable with this however some clients might be comfortable - other master therapists show videos of their work with clients and it is very helpful to show other therapists and potential clients the effectiveness of different therapies. If Dr. Stephanie were to identify that her work with you could be beneficial for a public video is this something you would consent to?
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, are you able to self-pay at $200 per hour in order to work with her? She does not accept insurance for Couples Therapy or Some Specific Therapy Procedures. She does accept insurance for some therapies.
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