Fillable Behavioral Health Emergency Response Plan (Erp) Template

Behavioral Health

Emergency Response Plan (ERP) - Spanish Version

Date Completed: ______________________

First Name: _____________________ Middle Initial: _____ Last Name: __________________ Gender: ____

Address: _______________________________________ City: ____________________ State: ________

Zip Code:________ Phone Number: ___________ Date of Birth: ____________ Primary Language: _________

Special Instructions (such as: housing, contact information or care of minor children, access codes, pet care,

cultural/religious considerations, service dog information, dietary needs, WRAP plan and Advance Directive etc.)

__________________________________________________________________________________

Emergency Contact Information

(Consent to release information must be obtained by treatment providers)

Name: _____________________ Relationship: _____________________ Phone #: __________________

Address: ____________________________ City: ______________ State: ________ Zip Code:__________

Case Manager Name: _____________________________________ Phone #: _______________________

Conservator Name:

____________________ Phone #: _______________________

(LPS-attach copies of documentation)

Medical Information

(For use by First Responders and emergency medical personnel only)

Mental Health and/or Substance Use: ________________________________________________________

Medical Conditions: ____________________________________________________________________

Allergies: ___________________________________________________________________________

Current Medications: List name, dosage & frequency (including herbal and over-the-counter):

__________________________________

Health Insurance Provider: _________________________ Insurance Phone #: ________________________

Subscriber’s Name: ______________________________ Insurance ID #:___________________________

Counselor/Therapist: ______________________________________ Phone #: ______________________

Psychiatrist:_____________________________________________ Phone #: ______________________

Primary Care:____________________________________________ Phone #: ______________________

Preferred Hospital: ________________________________________ Phone #: ______________________

Preferred Crisis House: _____________________________________ Phone #: ______________________

I, _______________ , authorize this form to be used and released to First Responders and emergency medical personnel.

Signature: _________________________________

Date: __________________________

Information Submitted by (

): ________________________________________________________

print name

Relationship to Consumer (

): _________________________ Phone #: _______________________

if applicable

Address: _______________________________ City: ______________ State: ______ Zip Code: _________

Signature: __________________________________

Date Signed: ____________________________

The ERP form is to be shared with First Responders and emergency medical providers and returned to the person presenting the form

once the information has been obtained. The ERP should not be placed in the consumer’s medical record without his/her consent.

7/29/11

Behavioral Health Emergency Response Plan (Erp) Template - Spanish Version Page 2

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