Simon Erlich Psychotherapy Consultation Request Form

Welcome - I am glad you are here.

Discovery calls are a relaxed and complimentary 20-minute conversation where we can explore what brings you to therapy and whether working together feels like a good fit. The discovery call will be held via my private and secure video portal, JaneApp.
Name

Preferred NameLast Name
Email
example@example.com
Phone Number (optional)
Please enter a valid phone number.

Please list a few preferred times for our discovery call.

Kindly confirm your timezone (e.g. PST; MST; EST; AST; NST etc...)
You are invited to share a few words about your hopes and intentions for working together.
Kindly share how you were referred to my work.
(e.g. personal referral, psychology today, google search, social media)
Should be Empty:

Welcome - I am glad you are here.