Request Appointment

To request a therapy appointment, please fill out this confidential form and I will get back to you as soon as I can (typically within 24 hours). If you are requesting an assessment, please fill out the details section at the bottom of the form.

***If you are experiencing a current mental health crisis and need immediate support to ensure your safety, please contact crisis support services within HRM at 902-429-8167 or 1.888.429.8167 (toll free) or contact 911

Request an Appointment

Please take a moment to fill out this confiential form.

First Name

Last Name

Age

Email

Phone number

Concerns/ isses (click as many as you need)

Abuse (emotional)

Abuse (physical)

Abuse (sexual)

Agoraphobia

Anger

Anxiety

Assertiveness

Body image

Brain injury

Depression

Divorce/ breakup

Eating disorder

Family issues

Health issues

Loneliness

Motivation

Obsessive-compulsive disorder

Panick attacks

Perfectionism

Procrastination

Relationship issues

Self-esteem/ confidence

Self-harm

Sexual assault

Shyness/ social anxiety

Sleep problems

Specific phobia

Stress

Suicidal thoughts

Traumatic event(s)

Work stress

Other (please specify in the space below)

Please briefly describe your concerns and the issues you would like help with in therapy.

Thanks for submitting!

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