Emergency Contact Release Form
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Client Name *
Client Street Address *
City *
State *
Zip code *
Phone number *
Email address *
Therapist name *
I hereby authorize the above named therapist or any mental health professional at the Center for Therapy & Counseling Services, LLC, to release any information needed to secure safety when suicidal, homicidal, or any information related to a medical concern or emergency to the emergency contact listed below: *
Required
Emergency contact name *
Relationship to the client *
Emergency contact street address *
Emergency contact city *
Emergency contact state *
Emergency contact zip code *
Emergency contact phone number *
Emergency contact email address
By typing my name below, I understand this release authorization is limited for the purposes and to the person listed above. I understand this release form is revocable at any time except to the extent that action has been taken on it already. An electronic signature may be accepted in lieu of the original signed form. *
Date *
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