Emergency Contact Information

Your full name:

Date of birth:

Home address:

Phone number:

Name of emergency contact:

Phone number for emergency contact:

Do you have a physical medical condition or disability that you think I should be made of aware?      Yes  /  No     If yes, please describe:

If a medical emergency arises during your session, what actions would you wish for me to take?

This information is kept confidential and secured in a locked cabinet along with any confidential notes I may maintain. I will not use this information except for in an emergency.

If during our work together any of the above information changes, please let me know.