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Dr. Kant LogoDr. Kant Logo
  • Home
  • Services
    • General Adult Psychiatric Services
    • Child and Adolescent Psychiatry
  • About
  • Forms & Links
    • New Patients
    • Office Forms
    • Medications / Refill Request Form
    • Links & Info
  • Telehealth
  • Contact Us

Personal Crisis Plan

Personal Crisis PlanNPCAnna2023-08-20T23:36:51-04:00

Personal Crisis Plan

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Patient Name*
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Responsible Party*
If patient is a minor or has a legal representative or guardian, additional information is needed.
Responsible Party*
Guardian/Legal Representative is required to attach supporting legal documentation.

If I’m feeling unsafe, I will go to the ER of local hospital, call Suicide Hotline 1-800-273-8255, or call my county’s crisis number.

(If patient is a minor (ages 14-18) he/she must sign this Registration-Assignment/Release/Consent to Treatment)

I certify that this data is true, correct & accurate. I understand that payment of this claim will be from federal & state funds. Any false claims, documents, or concealment of material facts may be prosecuted under applicable laws. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.

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New Patients: Request Initial Appointment
Existing Patients: Update Your Information
Pay Your Balance

Your account number can be found on your mailed statement.

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