Treating Healthcare Professional Form

Full Name of Healthcare Professional *
E-Mail of Healthcare Professional *
Please select the relevant Path of Love *
Full Name of Path of Love Applicant: *
E-Mail of Path of Love Applicant *
Please provide the address and phone number of your practice below.
Address *
Suburb/City/Town *
State/Province/Terr/Region
Postal/Zip Code *
Country *
Phone Number (Home) *
Phone Number (Mobile) *
Please share your credentials, thank you.
Is there anything you would like to share about the POL applicant (your client) that may be helpful for our workshop Facilitators and therefore beneficial for your clients well-being and retreat process? *
* I certify that I am the psychotherapist/psychiatrist/psychologist or other healthcare professional currently caring for the individual named above. I have read the Path Retreats Guidelines for Professionals, and (if I felt it was appropriate and/or needed) consulted with a Path Retreats Organizer or Facilitator. Assuming the truth and accuracy of all of the information provided to me about the program, and my professional experience working with the individual named above, my signature below verifies that the individual named above has the mental and emotional stability to participate in the Path of Love 7-Day Retreat.

Signature

(Please type your full name in the box): *

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