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DOMESTIC VIOLENCE
SEXUAL ASSAULT
SAAM 2023
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Are you or a loved one a survivor of sexual assault?
Yes, I am a survivor
Yes, my loved one is a survivor
No
Self-Love Support Group is for survivors of sexual assault and their loved ones. Please call Jerrica for more info at 903.295.7846.
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Emergency Contact Person (ECP)
If you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or in a crisis that we cannot solve, it may be determined that a higher level of care is needed. In this instance, an Emergency Contact Person (ECP) is required and will be contacted on your behalf in a life-threatening emergency only. Please enter this person's name and contact information below.
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Zip:
The Zip field is required. ex. 99999
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Phone Number:
The Phone field is required. ex. 999-999-9999
We will verify that your ECP is willing and able to go to your location in the event of an emergency. Additionally, if either you, your ECP, or we determine it necessary, the ECP agrees to take you to receive medical care. Your typed name and date at the end of this document serves as your signature and indicates that you understand your ECP will only be contacted in the extreme circumstances stated above.
Typed Name:
Date:
In Case of an Emergency
If you have a mental health emergency, we encourage you not to wait for communication from us but to do one or more of the following: Call 911 Go to the emergency room of your choice Call family or friend Call WCET hotline at 800-441-5555 Call Lifeline (National Crisis Line) at 800-273-8255
