Dr. Daniel Chorney & Associates

January 3rd, 2024

Our Self-Referral form is currently undergoing maintenance and is offline.

If you would like to make a new referral to our practice, there are two options currently available to you:

1) Email:

If you would like to save time, please send an email to our booking assistant and intake coordinator Grace (email below) and answer the questions to the right in your email. You can cut and paste the questions directly into your email if easier.

Grace (Intake Coordinator): dcahalifax@gmail.com


2) Voicemail:

If you would prefer to leave a voicemail for our intake coordinator, please call us directly at (902) 444-1160 extension 1 and leave a detailed voicemail that includes your name, phone number, email address (spelled out as well to avoid typos), and a brief description of your referral concern.


Please note that there may be a slight delay in processing referrals at this time, however, this will not impact your wait time at the practice.

1. Your Name:
2. Name of person referred (if not you):
3. Pronouns (e.g., she/her, he/him, they/them)
4. Date of birth of person referred:
5. Email address:
6. Phone Number for Contact:
7. Full Home Address (include City, Province, Postal Code):
8. Current Medication(s):
9. Emergency Contact (full name, phone number, and relationship to client):
10. Family Physician:
11. Brief description of your referral concern (e.g., 3-4 sentences describing concerns and examples of symptoms):
12. Are you looking to work with a specific psychologist at our practice (optional):