Emergency Contact Info

Contact Information

While we never hope for emergencies of any kind, we do need to plan for them. This is an emergency contact form to ensure that you have at least someone listed to contact in the case that there is a physical, mental health, or any other form of emergency. As I will be attending to the group, I will not be able to be listed. I will ensure that you connect with the necessary resources you need and coordinate with your emergency contact to follow up with any additional care needed.

Retreatant’s Name

First Last

Date of Birth

Primary Emergency Contact Name

First Last

Primary Emergency Phone Number:

Secondary Emergency Contact Name

First Last

Secondary Emergency Phone Number:

Signature

By signing this form, I give permission to Elisabeth Barahona to reach out to my contacts as necessary in an emergency situation. I acknowledge that if there is a need that exceeds general care during day-time hrs or a need that requires any extra support during night-time hrs, my contacts will be called. I also acknowledge that I have informed my friend/family member that they are my emergency contact and they should be available/on-call for any communication on my behalf. Elisabeth’s work # is: 574-574-5602 should they be wondering who a call might be coming from.

Signature

Date Signed

CONNECT

Hours

Thursdays: 7am – 6pm
Fridays: 7:00am – 4:00pm
(Appointment Only)

Address

Center on 5th
119 South 5th Street
Goshen, IN 46528

Phone

(574) 574-5602

Email

ebintegratedhealth@gmail.com