I agree that this person has been made aware that they are my emergency contact.*

I understand that it is my responsibility to notify Clear Path Coaching if my emergency contact information changes. *

I understand that I have provided an emergency contact on my Client Intake Form.

I authorize Alison Mello of Clear Path Coaching to contact my designated emergency contact if, in her reasonable professional judgment, she believes I may be at immediate risk of harming myself or others, or if she believes I am unable to maintain my own safety.

I understand that this authorization is intended solely to help protect my safety or the safety of others and will only be used when reasonably necessary.*