Contact Intake FormName *FirstLastName of Additional Client (if applicable)FirstLastPhone *Email *Address *Service(s) Requested *Individual TherapyCouples TherapyAssessmentCoachingBriefly describe the issues you wish to explore *Are there any concerns you have around physical safety, or do you have a history of self-harm? *YesNoIf Yes, please describe your concernWho referred you to Dr. Rotem Regev?DoctorTherapistFriendBCPAOnline SearchOtherIf Other, please provide detailsIn the event that Dr. Rotem Regev can only see you in a few weeks, would you prefer to be seen sooner by her trusted colleague? YesYes, only if it is a registered psychologistNo thanks, I'll wait CommentSubmit Form