Free Therapy Form

Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Country You Are Currently Located in*
State*
Location in Israel
Zip/postal code *
Email*
example@example.com
Phone Number*

Area CodePhone Number
Are you able to send and receive text messages on this phone?*

YesNo
How can we contact you?

EmailCallWhatsappSMS
Do you have the ability to use a smartphone, tablet or computer for the sessions?

YesNo
Would we be able to speak to your school to make arrangements for a web-based session?

YesNo
Are you able to have sessions by phone?

YesNo
Are you able to travel to a pre-determined location in Yerushalyim, where they have the ability for you to have remote sessions:

YesNo
What languages do you speak?*

EnglishHebrewYiddishOther
What's your gender?*

MaleFemale
Do you have a gender preference for your therapist?*

MaleFemaleNo Preference
Do you have a preference of the religious affiliation of the therapist?*

No preferenceChasidishLitvishSefardicModern OrthodoxSecularOther
What days and times are you available? Select all that apply

Sunday MorningSunday AfternoonSunday EveningMonday MorningMonday AfternoonMonday EveningTuesday MorningTuesday AfternoonTuesday EveningWednesday MorningWednesday AfternoonWednesday EveningThursday MorningThursday AfternoonThursday EveningFriday MorningFriday Afternoon
What would you like the therapist to know before your first session?*
School Information:
School Name:
School Contact Person:

First NameLast Name
Contact Person's Email
example@example.com
Contact Person's Phone Number:

Area CodePhone Number
Questions or Comments
Student
Please verify that you are human*
Should be Empty: