Book an Appointment with a Halifax Psychologist Online Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I identify my gender as:AddressEmail *Okay to email? *YesNoPreferred contact phone number *Okay to leave a message? *YesNoAlternate contact phone number *Okay to leave a message? (Alternate Number) *YesNoEducationN/APre-SchoolPrimaryGrade 1-3Grade 4-6Grade 7-9Grade 10-12High School DiplomaSome College/UniversityCollege/University DiplomaPost-College/UniversityIndividual Therapy or Couple’s Therapy?Individual TherapyCouple’s TherapyPartner's NameFirstLastPartner's Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Partner's AddressPartner's PhonePartner's EmailIf child, provide parent or guardian name(s):If child, provide guardianship status:Mother & Father (Married)Mother & Father (Separated: Shared Custody)Mother or Father (Separated: Sole Custody)Foster Care or Government CustodyOtherHow did you hear about these services?Friend or FamilyPhysician ReferralPsychologist ReferralEmployee AssistancePhone DirectoryAdvertisementInternetSchoolLecture or PresentationOtherType of service requested:Child/Adolescent AssessmentChild/Adolescent TherapyAdult TherapyParent ConsultationFamily TherapyCouples TherapyOtherBriefly state current concerns or situation:Has there been any previous assessment or therapy? Please describe:What is the desired outcome you hope for?Submit