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.