Book An Appointment with a Halifax Psychologist Online First Name Last Name Date of Birth ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember --01020304050607080910111213141516171819202122232425262728293031 I identify my gender as Your Address Email Okay to email? YesNo Preferred contact tel # Okay to leave a message? YesNo Alternate contact tel # Okay to leave a message? YesNo Education - please select - n/a pre-school primary grade 1-3 grade 4-6 grade 7-9 grade 10-12 high school diploma some college/university college/university diploma post-college/university Individual Therapy or Couple's Therapy? Individual Therapy Couple's Therapy Partner's First Name Partner's Last Name Partner's Date of Birth ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember--01020304050607080910111213141516171819202122232425262728293031 Partner's Address (if different) If child, provide parent or guardian name(s): If child, provide guardianship status: - please select - mother & father (married) mother & father (separated: shared custody) mother or father (separated: sole custody) foster care or government custody other How did you hear about these services? - please select - friend or family physician referral psychologist referral employee assistance phone directory advertisement internet school lecture or presentation other Please indicate how you heard about these services: Please enter the physician's name: Type of service requested: - please select - child/adolescent assessment child/adolescent therapy adult therapy parent consultation family therapy couples therapy other Briefly state current concerns or situation: Has there been any previous assessment or therapy? Please describe What is the desired outcome you hope for?