New Client Inquiry

Reach out to schedule your first appointment or ask any questions about our services.

We're here to help you take the first step toward wellness. Fill out the form below and our team will get back to you shortly.

Address: First Floor, 1331 Brenton Street, Halifax, NS B3J 2K5

Phone: (902) 407-1234

Email: admin@hubleycarruthers.com

Appointment Form

First Name*

Last Name*

Age Range*

Email Address*

Primary Phone*

Secondary Phone

Home Address

Name of Employer / School / Business

Occupation

Name of Family Physician

How did you find us?

Do you know of any first-order relatives (i.e. parents, children, partners or ex-partners, etc.) that have been or may be clients of our office?*

So that we can help you select the most appropriate psychologist, would you like to tell us a little bit about why you are seeking assistance?

In the case of Couples and/or Family Therapy we also need the following fields (for name of spouse/partner)

Therapy Partner's Name (First)*

Therapy Partner's Name (Last)*

Therapy Partner's Age Range*

Kindly be aware that certain third-party providers may require pre-authorization for services. Please indicate if you are a client of any of the following organizations: