Patient Information
- Full Name: _________________________ Date of Birth: //____
- Address: _________________________________________________
- Phone: (Home) _____________ (Cell) _____________ (Work) _____________
- Email: _________________________________________________
- Preferred Contact Method: □ Phone □ Email □ Text
Primary Emergency Contact
- Name: _________________________ Relationship: _________________
- Address: _________________________________________________
- Phone: (Primary) _____________ (Alternative) _____________
- Email: _________________________________________________
- Has permission to receive information about my care: □ Yes □ No
Secondary Emergency Contact
- Name: _________________________ Relationship: _________________
- Phone: (Primary) _____________ (Alternative) _____________
- Email: _________________________________________________
- Has permission to receive information about my care: □ Yes □ No
Healthcare Provider Information
- Primary Care Physician: _____________________________________
- Phone: _____________ Fax: _____________
- Other Mental Health Provider: ________________________________
- Phone: _____________ Fax: _____________
Emergency Services Authorization
- In case of psychiatric emergency, I authorize contact with:
□ Emergency contacts listed above
□ Local emergency services
□ Preferred hospital: ________________________________________
Crisis Planning
- Preferred crisis hotline: ____________________________________
- Previous psychiatric facility (if applicable): _____________________
- Known triggers or concerns: _________________________________
Authorization
I confirm that the information provided is accurate and authorize the use of this information in case of emergency.
Patient Signature: _________________________ Date: //____
Provider Signature: _________________________ Date: //____
Form Update Log
Last Updated: //____
Next Review Due: //____