Emergency Information for:

Medical condition(s)

Emergency contacts:

Name:

Phone number(s):

Relationship:

Name:

Phone number(s):

Relationship:

Primary Care Physician:

Contact Number(s):

Other physician:

Contact Number(s):

Medication(s):                          Dose(s):                              Reason(s):

By providing this information and signing this form, I am giving my counselor/therapist permission to use this information if he/she deems I become medically at risk while in his/her presence. I absolve him/her from responsibility for any resulting expenses incurred.

Signed:                                                                   Date: