* indicates required fields

Note: If you have been a patient here before, please fill in only the information that has changed.

A. Identification

Your Name *

Date of Birth*



Marital Status*

Home Address - Street*

Apartment #



Postal Code*

E-mail Address*

Skype Name

Home/Evening Phone

Calls will be discreet, but please indicate any restrictions:

Emergency Contact Person*

Relationship to you

Contact Phone Number*




B. Referral - Did someone refer you to Clear Path Solutions?

Referrer's Name

Referrer's Phone Number

Clinic/Hospital Name & Address

May I have your permission to thank this person for the referral?

How did this person explain how we might be of help to you?

C. Payment for Online Sessions: We will bill your card following each session.

Once we receive your form, we will contact you for your credit card information.

How would you like to receive your receipts?*