verified by Psychology Today verified by Psychology Today Directory
 
 
 
Hello and Welcome!

Please help me determine how I might best help you by answering the questions on the simple new client form below. All information will remain completely confidential.

Once you have hit submit and I have your information we are ready to begin your sessions. Choose the type of session you would like and
pre-pay for your time.

Name:
Date of Birth:
 Sex : Male Female
Address:
Phone number:
Email:
What would you like to accomplish with support & coaching?
Do you take any medication? Yes No
If so please list them, the dose, and what they are for below.
Are you now or have you ever been in therapy? Yes No
If so, please tell me what for:
Do you drink alcohol or take recreational drugs? Yes No
If so how much and do you think you have a problem:
Check here if you agree that the above information is true and correct.
 

Session Options:

1. Office Session
2. Phone Session
3. Instant Messaging (Using Yahoo Messenger available here or Skype available here)
4. Video Messaging with your webcam (Using Yahoo Messenger available here or Skype available here)
5. Email: (a one page email response to your concerns)

Payment Options:
Cash or Checks in person, eChecks and all major credit cards through PayPal.

Its very simple, just follow these 3 easy steps:

1. Choose the type of session you are paying for and click the "Buy Now" button.
2. If you have a PayPal account, log-in and pay.
3. If you do not have a PayPal account click on the lower left where it says:
    Don't have a PayPal account?
    Use your credit card or bank account. (where available)
    Then click "CONTINUE" and follow the step by step instructions.
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Full Session:
In Office, By Phone, Using Yahoo Messenger or Skype (50 Minutes)
$120.00
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Half Session:
In Office, By Phone, Using Yahoo Messenger or Skype (25 Minutes)
$60.00
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Email Session:
A one page email response to your concerns.
$100.00
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Pre Pay or Pay Co-Pay:
This link allows you to choose the amount you are paying, and should
be used to pay co-pays.
Co-Pay
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If you need to contact me in the meantime, please email mj@mjklimenko.com
Thanks Mary Julia Klimenko

Note: I am a Psychotherapist and Hypnotherapist, but because of unclear interstate laws if you do not live in California, I will only be providing you Coaching, using my expertise as a therapist as background.
Copyright© 2011 Mary Julia Klimenko Web Design acker design