Extra Information

3. Colleagues, Referrals, Collaborators, Resources, etc

TheraClosure specializes in sensitive notification to your <clients/patients>, and expects to take on the responsibility of notifying your <clients/patients> in the event of your death or incapacitation. However, some clinicians prefer that a colleague who knows you would make those initial calls to <clients/patients>. If that is your preference, we would contact this colleague, if needed, and confirm s/he is available. If so, we would provide the <client/patient> contact list. If not, we would assume responsibility for notification. Who do you want to reach out by phone to notify your <clients/patients> in the event of your death or incapacitation?

TheraClosure

A colleague

You answered that you want a colleague to make the initial phone notifications of your <clients/patients> in the event of your death or incapacitation.
Please enter your colleague’s name, email address and phone number so that we can contact your colleague if necessary.Please be sure to contact your colleague now to confirm his/her willingness to take on this role.

If TheraClosure needs to make a notification to your current and previous <clients/patients>, we will provide our contact information in case they have questions immediately or at a later time. If you wish, we can provide the name and contact information of a colleague who would be available to answer questions.
Do you want to us to provide a colleague’s name who would be available to answer questions?

NoYes

You indicated that you want us to provide <clients/patients> with the name of colleague who can answer questions immediately or at a later time in the event of your death or incapacitation. Please enter that colleague’s name, email address and phone number so that we can contact your colleague if necessary.Please be sure to contact your colleague now to confirm his/her willingness to take on this role

If you wish, TheraClosure will contact your preferred referrals to see if they are able to take on one or more of your <clients/patients>, If so, we will facilitate transfers. We will use our own referral sources as needed to help find tailored referrals for your <clients/patients> Do you have colleagues you would wish to refer your <clients/patients> to ?

NoYes

You indicated that you would like TheraClosure to first try to refer your <patients/clients> to colleagues known to you. Please provide that list of colleagues and their contact information. TheraClosure will contact them to see if they are willing to take on any of your patients. TheraClosure will take responsibility for locating appropriate referrals if your colleagues are unavailable.

Do you have a colleague or colleagues who you would like <clients/patients>, who are mid-assessment (including psychological testing) to complete their evaluations/testing with ?

NoYes

You indicated that you wish to identify colleagues who would be able to continue psychological evaluations or testing consultations on your behalf. Please list those colleagues and their contact information here.

Do you have professional contacts (e.g., therapists, nutritionists, psychiatrists with whom you routinely work ; supervisees; accountants; billers; people who administrate teaching appointments, memberships to professional organizations) you you would us to notify in the event of your incapacitation/death? c

NoYes

You indicated that you wish to identify professional contacts you would like us to notify in the event of your death or incapacitation. Please list here the names and contact information for collaborators, supervisees, teaching appointments, professional organizations, accountants, billers and others we should notify.

TheraClosure will call all your active <clients/patients> and write to all your previous <clients/patients> to sensitively and empathically convey your situation. Some therapists also wish to have a letter written in their own voice on file that we send. Do you want to write such a letter that we keep on file?

NoYes

You indicated that you would like to write a letter that TheraClosure would provide patients in the event of an emergency. Please type or paste your letter here.

Do you have resources (e.g., a website, a clinic) that you routinely suggest to your <clients/patients> ? Would you like to provide us a list of such resources?

NoYes

You indicated that you wish to identify resources that you typically refer your <patients/clients> to. Please list those resources here.

Do you have specific requests for referrals or disposition of particular <clients/patients> ?

NoYes

You indicated that you wish to provide specific instructions for some of your <patients/clients>. For security reasons, please do not provide the names of any patients. Instead, list patients only by initial and DOB here. Write your specific instructions for how you would like TheraClosure to try to handle notifying and referring out these specific individuals. (You may also indicate exceptions to your form responses, above.)
(Note that you will be able to update this information at any point.)