Maria Skedros | SimplePractice

Who would be receiving care?

My partner and me

Your info

First name

Last name

Phone

Name you go by

Gender

First name

Other

Are you looking for couples or Individual therapy?

Reason for care

My specialty is working with couples and individuals and sexual health. I only offer therapy to those that are wanting to work on their sexual relationship with either themselves or others. Is this the reason you are seeking therapy?

Yes No

Are you looking for couples or individual therapy?

Client Preferences

For in-person sessions, my office is located at 3980 S. 700 E. Ste. 22, Millcreek, Utah. For Telehealth appointments, I provide HIPPA complaint Telehealth services. Would you prefer in-person therapy or Telehealth?

In-person Telehealth

Billing & Payment

I do not accept insurance, but I will provide a superbill that you can submit for reimbursement. My fees are $185 for 50 minute individual sessions, and $210 for 50 minute couples sessions, which are scheduled at three week intervals, on the same day and the same time for your convenience. Do these fees work for you?

Yes No

Administrative

Sessions are scheduled on either every other week or every third week, on the same day and the same time. For example, your session might be every three weeks on a Monday at 10:00 am. Does this work for your schedule and budget?

Yes my schedule is flexible Yes, but my schedule is not very flexible so I would need a specific day and time No

My office hours are Mondays from 12:00 pm to 5:00 pm (last client start time at 5:00), Tuesdays from 9:00 am to 4:00 pm (Last client start time at 4:00 pm) and Wednesdays from 2:00 to 4:00 pm (last client start time at 3:00 pm) Do my office hours work with your schedule?dule?

Yes No

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.