Personal Crisis Plan

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Patient Name*
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Responsible Party*
If patient is a minor or has a legal representative or guardian, additional information is needed.

If I’m feeling unsafe, I will go to the ER of local hospital, call Suicide Hotline 1-800-273-8255, or call my county’s crisis number.

(If patient is a minor (ages 14-18) he/she must sign this Registration-Assignment/Release/Consent to Treatment)
Clear Signature

I certify that this data is true, correct & accurate. I understand that payment of this claim will be from federal & state funds. Any false claims, documents, or concealment of material facts may be prosecuted under applicable laws. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.

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