Therapy Services Interest Form

Therapy Services Interest Form

This form will help us answer your questions, get you a quote regarding cost and recommend the right therapist that will fit your needs, budget and schedule. After submitting this form, you will be directed to an online scheduling portal where you can request an appointment.
* Please Note: Because our providers are licensed in the state of Maryland, we see clients who reside in or who are physically in Maryland at the time services are rendered. *
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
How were you referred to us?*

Additional Questions
If you are interested in Couples Therapy, are you interested in learning more about Private Intensive Retreats and / or Couples Weekend Workshops with Dr. Stephanie?

YesNo
Are you interested in learning more about the Safe and Sound Protocol integrated with EMDR Therapy? (Can be used to treat: Autism Spectrum Disorder, ADHD, PTSD, chronic pain and other related disorders)

YesNo
What questions would you like to have answered when we respond to you?
Should be Empty:

Insurance