Contact This form is not HIPAA-compliant. Keep this in mind when submitting personal health information (PHI). * Ok, got it. Name * First Name Last Name Phone * (###) ### #### Email * Please ONLY submit this form if you are genuinely interested in getting started and want to see if we are a great fit/really want to learn more. ***I set aside time to respond to you and save a spot for your genuine interest in getting started! * Got it! Yes, I am motivated and genuinely interested in getting started. Please share a bit more about why you are seeking therapy at this time * If Dr. Horevitz has a waitlist, are you willing to be added? * How did you hear about me? * Google Facebook Instagram Word of Mouth Other What is your motivation, 1 out of 5 (5 being highly motivated) to get started, get relief, and make progress? * 1 (Not Motivated) 2 3 4 5 (Highly Motivated) Would you like me to reach out to you by texting you or by emailing you? * Text me! Email me (make sure to check your junk mail as well, within the next 24 business hours) Text and email me, please! I am an out-of-pocket practice and do not bill insurance. * Confirm by typing "I understand": If you selected to be “texted” above, please type the phone number you want us to text you at OR put “N/A”: * Thank you for filling out this form, I will get back to you in less than 24 business hours! Please make sure to check your junk mail. * Ok, got it! Thank you!
