Momentum-cares | EMERGENCY CONTACT FORM

Date(Required)

Consumer Name:(Required)

First Last

SSC:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Cell:(Required)

Email:

Parent Name (if applicable):

First Last

Known Allergies:(Required)

In Case of Emergency, please list two (2) people over the age of 18 who can be contacted:

Name:(Required)

First Last

Contact Number:(Required)

Other Number:

Contact Email:

Name

First Last

Contact Number:

Other Number:

Contact Email:

Is there a Primary Care Physician:(Required)

Is there a Mental Health Provider:(Required)

Clinic/Doctor Name:(Required)

Phone Number:(Required)

Clinic/Therapist Name:(Required)

Phone:(Required)

Suicide Prevention Hotline 1-800-273-8255 Maryland Suicide Hotline 410-752-2272 Maryland Youth Crisis Hotline 1-800-442-0009

Describe what a crisis looks and feels like to you?(Required)

What is different in times of crisis than in other times of your life? (Like “bad days” for instance)

What things can you do to help clam your self when you become upset?(Required)

Name at least 3 people you know you can reach out to if you need assistance.(Required)

Email of Person Completing Form:(Required)

EMERGENCY CONTACT FORM