Info

Name:

Address:

Phone:

Email:

Contact person:

Contact person’s email or phone:

Local Contact person (if different)

Local contact person’s info:

Instructions for gaining entry to house:

Preferred hospital:

Preferred method for check in, e.g. phone or email:

I will contact you every morning and if I don’t hear back within 24 hours I will call and if there’s no answer I will send a trusted person to enter your home or call 911.

Katherine Schneider, Ph.D.
Senior Psychologist, Emerita
Counseling Service
University of Wisconsin-Eau Claire
schneiks@uwec.edu
Author of Occupying Aging: Delights, Disabilities and Daily Life, To the Left of Inspiration: Adventures in Living with Disabilities and a children's book Your Treasure Hunt: Disabilities and Finding Your Gold
Blog: http://kathiecomments.wordpress.com