Appointments

Please fill out the below appointment form to the best of your ability and someone from the Hubley Carruthers office will be in touch with you as soon as possible. Thank you.

Appointment Form

First Name*

Last Name*

Date of birth (yyyy/mm/dd)*

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 Date of Birth (yyyy/mm/dd)*

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: