Emergency Response Counseling Liability Release
Please complete this form to participate in emergency response counseling. Your information will be kept confidential and is necessary for your safety and our records.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Emergency Contact
*
Please Select
Parent/Guardian
Spouse/Partner
Sibling
Friend
Other
Do you have any known allergies? If yes, please specify.
Are you currently taking any medications? If yes, please list them.
Have you previously received counseling or mental health support?
*
Yes
No
Briefly describe the reason for seeking emergency response counseling.
*
Signature
*
Submit
Submit
Should be Empty: