Get Started with Klein Therapy

Your Information

First Name

Last Name

Today's Date

Street Address

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Employer

Email Address

Are you comfortable receiving invoices over email? Yes No

Date of Birth

Age

How were you referred to me?

Have you been in therapy before? Yes No

Emergency Contact Information

Full Name

Relationship to You

Phone Number

Medical Information

If you take psychiatric medications, please list them here:

Please list any other present medical conditions & medications taken:

Name of Prescribing Physician(s):

Klein Therapy Policies

Please read the following policies carefully.

Therapy Sessions

Therapy sessions are generally scheduled on a weekly basis, though at times it becomes important to meet more frequently. The duration of treatment varies based upon each client's particular needs.

Fees

Therapy appointments are 50 minutes. I issue statements on a monthly basis and ask for payment by the 15th. Acceptable forms of payment include checks, credit cards, PayPal, and Venmo.

Insurance

As an out-of-network provider for all PPO insurance plans, I will provide a monthly invoice that you can submit to your insurance company for reimbursement...

I have read and understood the Klein Therapy policies

Review & Submit

Please review your information below and submit by clicking the button.

I confirm that the information provided is accurate to the best of my knowledge.