Your Name *

First Name

Last Name

Phone

(###)

###

####

Where do you reside?

New York

California (Coaching Only)

New Jersey

Florida

Vermont

I want to hire you as a Coach so location does not matter

I want to hire you to speak, train or teach so location doesn't matter

What kind of sessions are you looking for?

Video and phone psychotherapy sessions are available for NY, NJ and FL residents! International Coaching is available anywhere in English.

Video

Phone

Walk-and-Talk in CA

No preference/I don't know yet

Hire for Speaking Engagement

Health Insurance options *

Several health insurance plans cover teletherapy. Coaching is out of pocket payments only.

I will pay out of pocket

I will use my health insurance coverage (BCBS, United, or Cigna)

Aetna Out-of-Network

Other Out-of-Network Insurance Plan

EAP

Not sure

How did you hear about my services? *

Friend/Family

Community Event/Workshop/Class

Referral from another professional

Health Insurance Company

EAP

Psychology Today

General Internet Search

Anat Samid's Blog

Social Media (Facebook, Twitter, Instagram)

Other