Emergency Contact Information
|Your full name:
|Date of birth:
|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.