Trauma Recovery Counseling Liability Release Form

Trauma Recovery Counseling Liability Release Form
Please complete this form to acknowledge the liability release before participating in trauma recovery counseling. Do not provide sensitive health information.
Participant Information
Participant Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Emergency Contact
Emergency Contact Name
First NameMiddle NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signature and Date
Participant Signature
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Signing Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: