Emergency Contact Release of Information

EMERGENCY CONTACT RELEASE OF INFORMATION

A Holistic Elevation Clinician will need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. Holistic Elevation also needs a contact person who we may contact on your behalf in a life threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency.

Client’s Full Name:

Current Location/Address:

Emergency Contact :

Contact Name:

Relationship

My emergency contact person’s address

My emergency contact person’s phone:

Information shall consist of:

Duplicate records and/or verbal consultation concerning treatment and/or education.

Specifically:

-

I have read the information provided above and discussed it with my therapist.

I give consent for Holistic Elevation to contact my emergency contact in an emergency situation.

I understand the information contained in this form, and all of my questions have been answered to my satisfaction.

I do not wish to disclose emergency contact information.

*Parent, Guardian or Legal Representative Name (if minor or needed otherwise)

Date

Parent/Guardian/Legal Representative Signature

تم تحديد وضع الرسم. يتطلب الرسم استخدام الماوس أو لوحة اللمس. لإمكانية الوصول إلى لوحة المفاتيح، حدد كتابة أو تحميل.

*This consent is valid until client discharge.