* 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*

    Age*

    Title*

    Marital Status*

    Home Address - Street*

    Apartment #

    City*

    Province*

    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*

    City

    Province

    Country

    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?*