Emergency Medical Profile
Jane Marie Henderson
Printed on product as “Janie”
DOB:09 / 14 / 2017
Photo of Patient
Primary Medical Condition
Autism Spectrum Disorder (Level 3 / Non-Verbal)
Life-Saving Alerts — Critical
AUTISM / NON-VERBAL. FLIGHT RISK. HIGH SENSORY OVERLOAD.
Vital Medical Alerts
Communication & Mobility Needs
Janie cannot speak to first responders. She communicates via basic gestures, a picture board, or iPad app. Does not understand commands under stress.
Special Instructions for First Responders
Extreme fear of sirens, flashing lights, and loud voices. High risk for elopement (running away) when panicked. Approach slowly at eye level. Avoid touching her without warning. Do not restrain unless absolutely necessary for safety. Responsive to tactile pressure or light singing.
Emergency Contacts
Primary Emergency Contact
Sarah Henderson
Mother
Backup Emergency Contact
Jennifer Henderson
Aunt
Additional Emergency Contact
Michael Henderson
Father
Patient Demographics
Home Address
12204 Deer Creek Court
Delphi, IN 46923
Medications & Dosage
-
Guanfacine (Intuniv) — For hyperactivity and emotional regulation
1mg — 1x Daily (Morning)
-
Sertraline (Zoloft)— For severe anxiety and repetitive behaviors
25mg — 1x Daily (Morning)
-
Melatonin For sensory-related sleep disruption
3mg
Clinical & Insurance Details
Primary Care Physician
Delphi Pediatrics (Dr. Larson)
Insurance Provider & Policy # (optional)
Anthem Blue Cross / #M-883214-04
Insurance Card — Front
Insurance Card — Back
Legal Authorization
I authorize emergency medical personnel and first responders to access the information on this profile for the purpose of providing emergency medical care to the individual named above. This information is accurate to the best of my knowledge as of the date listed below.
Form Completed By
Sarah Henderson (Mother)
Date Completed
06 / 16 / 2026