Contact or self-referral form

Important Information

Once completed, this form with be encrypted and sent directly to our administrative staff. You should receive a response within 7-10 business days. If you are concerned your referral has not been received, please contact us by phone at the number below

902-370-2655

Your full name

Phone Number (no spaces or hyphens)

Email address (optional)

Is it acceptable to leave a voicemail at the number provided?

Yes please leave a message

No, please do not leave a message

Please provide any additional information that you think is relevant and can help us match you with the appropriate clinician:

Your information will be encrypted.