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.