This form must be completed by a PARENT/GUARDIAN, not by the patient.
Our online forms use SSL encryption to maintain secure transmission of medical information.
Forms MUST be submitted online.
This form will take approximately 30 minutes to complete. It can not be saved and continued at a later time. Please complete the form using a laptop or desktop computer. This form can not be completed on a tablet or phone.
The Possibilities Clinic requires one Point of Contact Person who will be responsible for arranging all appointments and notifying the other custodial parent.
Please note: that in cases of Sole Custody, Shared Custody or Guardianship you must bring a copy of your Legal Custody Agreement to the first appointment.
List Patient's parents. Indicate all that apply:
List Patient's siblings. Indicate all that apply:
If you selected NO this completes your Intake Form.
We will NOT be proceeding with your referral. Please see your family doctor/paediatrician about a referral to an alternate provider.