halifax, nova scotia

psychological services for unique people

Assessment Request Form

We attempt to check that forms are complete before your request is emailed to us.
Required fields are marked by an *.
If you enter a valid email address, we also email you a copy of your request.

At the bottom of the form there are 3 Options:
  • Send . . . attempts to verify and then email us your information.
  • Reset . . . clears the form.
  • Quit . . . returns you to the previous page.
Contact Information:
*Name *Last: *First:
In order to contact you, we need at least one phone number
*Phone Primary:  Alternate: 
Email If you enter a valid email address, we also email you a copy of your request.
Assessment Request:
Who is this assessment being requested for?
Give client name, age and relationship to you (e.g., child, self, other)
*Full Name: *Age: *Relationship:
*Reason
Why is this assessment being requested: (e.g., learning challenges, attention issues, social skills concerns, concussion/brain injury, etc.)
Erica Baker psychological services limited
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