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 * would Additional event 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 sourceIf 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