* indicates required fields
Note: If you have been a patient here before, please fill in only the information that has changed.
Your Name *
Date of Birth*
Home Address - Street*
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 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?*
By e-mailBy regular mail (Canada Post)