• Date of Birth*
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  • Are you able to send and receive text messages on this phone?*
  • How can we contact you?
  • Do you have the ability to use a smartphone, tablet or computer for the sessions?
  • Would we be able to speak to your school to make arrangements for a web-based session?
  • Are you able to have sessions by phone?
  • Are you able to travel to a pre-determined location in Yerushalyim, where they have the ability for you to have remote sessions:
  • What languages do you speak?*
  • What's your gender?*
  • Do you have a gender preference for your therapist?*
  • Do you have a preference of the religious affiliation of the therapist?*
  • What days and times are you available? Select all that apply

  • School Information:

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  • Should be Empty: