Self Referral Form - Emerge Advocacy

Emerge’s Support After Hospital.

Self Referral: Consent for Follow-up Support

Name*

First

Last

Date of Birth

Address*

Mobile number*

Gender

Medical Conditions/Allergies*

Are there any medical conditions or allergies we should be aware of?

Emergency Contact Name & relationship to you

Emergency Contact's Phone Number*

Emergency Contact's Address *

Emergency Contact's Email address*

Which hospital were you seen at / Which is your local hospital?*

I confirm that I have read & understood the information on this page and that I consent to Emerge providing follow up support to myself

I confirm that I have understood that Emerge is not a crisis line, that the Emerge phone is not always being monitored and that I therefore need to contact emergency services in the event of a crisis situation.

This field should be left blank

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