IN AN EMERGENCY. A special mobile phone is held by a member of the Management Committee; if there is an emergency at the Hall please call the number below to obtain guidance on the issue: Emergency telephone no: 00000 000000
IN AN EMERGENCY. What do you want your caregiver to do in an emergency? After calling emergency services, who else should be notified? List names and numbers here. Name: Name: Name: Name: Phone Number: Phone Number: Phone Number: _ Phone Number: SAMPLE DAILY SCHEDULE: 12:00am
IN AN EMERGENCY. You may contact the Xxxxx Behavioral Health Community Crisis Stabilization program: 000 000 0000, you may also go to the nearest emergency room or dial 911. You can contact me via email, text and voicemail and I will return your call within 24hrs, during business hours. EMAIL/SOCIAL MEDIA: In general, email/text is the quickest way to reach me and used to communicate appointment logistics and/or general information. I do not use email or texting to provide therapy and be aware that email/text conversations can become part of your legal record. Please reserve confidential and sensitive therapeutic topics for the clinical hour, to protect your privacy and the integrity of the therapeutic relationship. Additionally, out of concern for your confidentiality and my privacy, I do not accept friend requests or contact requests from clients on social networking sites (Facebook, LinkedIn, etc)
IN AN EMERGENCY. You agree that We and Our agents, representatives and contractors may enter the Supply Address if You are not there provided that the Supply Address is left no less secure by reason of such entry and provided that We pay You reasonable compensation for any damage caused to Your property by Us or by Our agents, representatives or contractors in obtaining such entry.
IN AN EMERGENCY the CVL IM shall, within a reasonable time of the occurrence of the Emergency, give notice to the Adjacent Facility Owner:
IN AN EMERGENCY. Contact me via text, e-mail and voicemail. You may also go to the emergency room, dial 911 or Crisis Hotline number 888-724- 7240.
IN AN EMERGENCY. Outside of normal business hours, calls may be made to either Xxxxx Xxxxxx Xxxxxxxxx, Director of the Xxxx Din of America, at (000) 000-0000 or Rabbi Xxxxxxx Xxxxxx, Xxxxx of the Xxxx Din of America, at (000) 000-0000.
IN AN EMERGENCY the Load Entity agrees to expeditiously open the interconnection disconnect switch upon notification from the PG&E Designated Switching Center.
IN AN EMERGENCY. Emergencies occurring after office hours may require you contacting me at the number above. I will make every effort to make myself available for your care. If, however, you are unable to contact me during an emergency, call 911 or go to the emergency room of the Community Hospital of the Monterey Peninsula (CHOMP) or the Xxxxxxxxx Medical Center. XXXXX also has a crisis line at 000-000-0000. The National Suicide Prevention Lifeline Call 0-000-000-0000 ENDINGS: You may end therapy at any time. A final phone call or session is requested for closure. PRIVACY POLICY: By signing below, you acknowledge receipt of my Notice of Privacy Practices. This Notice provides information about how I may use and disclose your private health information. I encourage you to read it carefully. (Notice of Privacy Practices available online at xxx.xxxxxxxxxxxxxxxx.xxx or available in the office) If you have any questions about the Notice or any of the above, please feel free to ask. _
IN AN EMERGENCY. Please note that I will not be available for clinical emergencies, either within business hours or after hours. In the case of a clinical emergency, please call the King County Crisis Line (000-000-0000), call 911, or go to a hospital emergency room. Once you are able, please do inform me of the emergency that has occurred. DISCLAIMERS: It is understood that any agreements made are between you and I only. I also cannot be responsible for the care provided by professionals or groups that I refer you to. PRIVACY POLICY: By signing below, you agree to understanding and upholding the entirety of this Treatment Agreement document. By signing below you also acknowledge receipt of my HIPAA Notice of Privacy Policies (the very last two pages of this document). This Notice provides information about how I may use and disclose your private health information. I encourage you to read it carefully. My Notice is subject to change. Client Signature Client Printed Name Date Second Client Signature Second Client Printed Name Date Therapist Signature Date Clarity Counseling Seattle, PS 0000 Xxxxxxxx Xxx X, Xxxxx 000 Xxxxxxx, XX 00000 000-000-0000 xxx.xxxxxxxxxxxxxxxxxxxxxxxx.xxx xxxxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx INTAKE FORM Please take a few moments to fill out the following 3 pages of the Intake Form, as it is helpful for your therapist to understand some of your past and present experiences and challenges. *If you are attending couples counseling, please have each partner fill out this Intake form. Thank you. Today’s Date First Name Last Name Address City State Zip Is it alright to send mail to this address? Y / N Email Address Home/Cell Phone Work Phone Is it alright to call you at home? Y / N Is it alright to call you at work? Y / N Date of Birth Emergency Contact/Relationship: Phone: ---------------------------------------------------------------------------------------------------------------------------------------------------------------- Occupation: Military? Date and branch: Have you participated in counseling with a therapist or psychiatrist in the past? If so, when? For what reasons? How was that experience for you? Are you currently taking any psychiatric medications? If so, which ones, for how long, and to treat what issue(s)? Are you currently taking any other prescribed medications? What would you say are your current life stresses? Please circle any of the following issues that currently pertain to you: Depression Suicidal Thoughts Career/Work Self –Cont...
