Contact Intake FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastName of Additional Client (if applicable)FirstLastPhone *Email *Address *Address Line 1CityState / Province / RegionPostal CodeService(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? *YesNoPlease describe your concern *Who referred you to Dr. Rotem Regev?Please Select...DoctorTherapistFriendBCPAOnline SearchOtherName of referral source to be wish If 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 waitSubmit Form