E-Therapy Emergency Contact Information Form
Client Information
Full Name
Date of Birth
Address
Phone Number
Email
Emergency Contact Information
Please provide at least one emergency contact.
Contact Name
Relationship
Phone Number
Email
Secondary Emergency Contact (optional)
Contact Name
Relationship
Phone Number
Email
Local Emergency Resources
Please list the phone number and location (address/city) of your local emergency services (e.g., Police, Hospital).
Local Police
Nearest Hospital
Other Relevant Local Resources
Additional Information
Anything else your therapist should know in the event of an emergency