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PATH Membership Application

Thank you for your interest in joining PATH! We're excited to learn more about you. Please share the following information so that we can confirm your membership.

What should we call you?

How should we be in touch?

Where do you live?

Where do you work?

Under what professional degree are you licensed?

Under what professional degree are you licensed?
A
B
C
D
E
F
G
H
I

Please list any of the following that you have:

District of Columbia License Number

Maryland License Number

Virginia License Number

What would you like us to know about you?

What do you hope to gain from your membership in PATH?

Please list any of the following that you have:

Where did you learn about ketamine and psychedelic assisted psychotherapy?

Where did you learn about ketamine and psychedelic assisted psychotherapy?

Do you want to be included in our Provider Directory?

Do you want to be included in our Provider Directory?
A
B