Relationship Recovery Support Group Intake Form

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* The Zip field is required. ex. 99999
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* Email field is required.
*May we contact you with group updates via email, phone call, text message? Select all that apply:
Email
Phone Call
Text Message
Please do not contact me
*I am interestested in the following group:
Longview
Marshall
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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* The Zip field is required. ex. 99999
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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.
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