Telehealth Emergency Plan

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EMERGENCY PLAN - TELEBEHAVIORAL HEALTH COUNSELING AND PSYCHOTHERAPY
SERVICES

Universal Emergency # in the U.S.: 911
Crisis Text Line: 24/7 text support - text HOME to 741741

Emergency Plan Agreement
By signing below, I certify the accuracy of the included information. This information is provided to assist in
the case of a life-threatening emergency involving significant physical harm, significant and imminent suicidal
thoughts and/or behavior or homicidal thoughts and/or behavior occurring between sessions or within sessions with Heather Moller, LCSW, RYT500. Should such a situation arise I agree to contact: 911, my Emergency Contact Person, the local Mental Health Crisis line, local law enforcement, my primary care physician, or go to the nearest hospital emergency for help. I understand that I can call my therapist by phone at 850-629-9449 but I may have to leave a voice message, which may not be checked for some time. I understand that my therapist does not offer 24-hour availability and if I am in need of urgent support, then I am responsible for enacting an emergency safety plan by contacting the resources named on this form. In life threatening emergencies, call local 911, your emergency contact person, or go directly to the nearest hospital emergency room. I understand that my therapist will also use the above contacts to protect me and/or others if life threatening situations occur.

Electronic Signatures
Each party agrees that the electronic signatures, whether digital or encrypted, of the parties included in this Agreement are intended to authenticate this writing and to have the same force and effect as manual signatures. Delivery of a copy of this Agreement or any other document contemplated hereby bearing an original or electronic signature by facsimile transmission (whether directly from one facsimile device to another by means of a dial-up connection or whether mediated by the worldwide web), by electronic mail in “portable document format” (“.pdf”) form, or by any other electronic means intended to preserve the original graphic and pictorial appearance of a document, will have the same effect as physical delivery of the paper document bearing an original or electronic signature.

Email *

Name *

Date of Birth *

YYYY

Date Completing this Form *

YYYY

Physical Address Where Sessions Will Occur (Street, City, State, Zip Code *

Emergency Contact Person 1 Name, Phone Number & Relationship *

Emergency Contact Person 2 Name, Phone Number & Relationship *

Local Law Enforcement Phone Number (City Police or Sheriff depending on which is active in your location) *

I agree to the above policies about how emergencies will be handled. I understand that my therapist is unable to guarantee crisis services and that I am responsible for enacting my safety plan between sessions. I further understand that my therapist may enact this safety plan during sessions if the need arises. I affirm that I am the person named above and agree that checking the box below serves as my electronic signature. *

Yes, I agree.

Required

A copy of your responses will be emailed to the address you provided.

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