Telehealth

Aaron Oravetz, LMFT # 123338

(916) 250-1104

EMERGENCY CONTACTS

In the event of an emergency, I authorize Aaron Oravetz, LMFT to contact the following persons whom live within a five-mile radius of my home to 1.) verify my location, 2.) verify my welfare, 3.) give him any and all information he deems necessary to verify that I am not experiencing an emergency. In the event that I am experiencing an emergency, I authorize Aaron Oravetz, LMFT to disclose relevant information to the named contact person(s) to ensure I get the emergency care I need. I understand Aaron Oravetz, LMFT will call the contact people named in the order I list them on this form. This list will remain effective for the duration of therapy, or until I choose to update it. I understand it is my responsibility to make updates to this form should any contact information for my named emergency contacts change.

Name:__________________________ Phone:__________________________

Address:_________________________ Relationship to patient: _____________

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Name:__________________________ Phone:__________________________

Address:_________________________ Relationship to patient: _____________

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Print Patient Name_____________________ Date:______________

Patient Signature:_______________________