Pre-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. If you are requesting a teletherapy appointment you will need to submit your paperwork online through your patient portal in advance of your appointment or via email to your therapist or to email@example.com. You will receive your registration paperwork through the portal or you can find it on the website - https://www.drstephanieonline.com/resources/forms/ The registration needs to be on file before their initial teletherapy appointment can be confirmed.
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
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)
Repair For Problems on a Work Team or Business Concern
How were your referred to us?
Personal Referral from Friend or Family Member
Gottman Referral Network
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)?
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
Right now, all locations are doing teletherapy until sometime in 2021 except very limited number of sessions at the Laurel office.
Videoconference (HIPAA Compliant, Your Therapist Will Send You an Email Invite)
Laurel Location Howard County (Dr. Stephanie is seeing a few clients in-person ).
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
$120- $140 per One Hour Session Without Using Insurance (Jacquean Kosh, Sophia Rizvi, Mordecai Andemichael, Monique Woodby, Domenica Carrese, Kristen Paul)
$225 per One Hour Session with Dr. Stephanie
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. Also include the phone # for Member/Provider Services on the back of your card. 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?
Dr. Stephanie does not accept insurance for couples therapy or intensive EMDR trauma therapy. Are you interested in working with her at a fee of $225 per hour?
Dr. Stephanie believes that intensive one-day or two-day private therapy retreats 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?
Do you understand that hourly 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
Should be Empty: