Please complete this entire document Step 1 of 3 33% Date(Required) MM slash DD slash YYYY Consumer Name:(Required) First Last SSC:(Required) Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell:(Required)Email: Parent Name (if applicable): First Last Known Allergies:(Required)In Case of Emergency, please list two (2) people over the age of 18 who can be contacted:Name:(Required) First Last Contact Number:(Required)Other Number:Contact Email: Name First Last Contact Number:Other Number:Contact Email: Is there a Primary Care Physician:(Required)YesNoIs there a Mental Health Provider:(Required)YesNoClinic/Doctor Name:(Required) Phone Number:(Required)Clinic/Therapist Name:(Required) Phone:(Required) CRISIS PLANSuicide Prevention Hotline 1-800-273-8255 Maryland Suicide Hotline 410-752-2272 Maryland Youth Crisis Hotline 1-800-442-0009 Describe what a crisis looks and feels like to you?(Required)What is different in times of crisis than in other times of your life? (Like “bad days” for instance) What things can you do to help clam your self when you become upset?(Required)Name at least 3 people you know you can reach out to if you need assistance.(Required)Email of Person Completing Form:(Required)