Personal Crisis Plan "*" indicates required fields Today's Date MM slash DD slash YYYY Patient Name* First Name Middle Initial Last Name Email* Date of Birth* MM slash DD slash YYYY Responsible Party* Patient Guardian or Legal Representative If patient is a minor or has a legal representative or guardian, additional information is needed.Responsible Party* First Last Responsible Party Email* Relationship to Patient*Guardian/Legal Representative is required to attach supporting legal documentation. My Triggers:*Thoughts/Inside Warnings:*Outside Warning Signs:*When I Notice My Triggers I Will:*When Others Notice I’m Upset I’d Like Them To:*Things That Help Me Stay Better Now:*Things That Help Me Stay Well on a Regular Basis:*Things That Make Me Feel Worse:*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. Patient Signature*(If patient is a minor (ages 14-18) he/she must sign this Registration-Assignment/Release/Consent to Treatment) Reset signature Signature locked. Reset to sign again Responsible Party Signature* Reset signature Signature locked. Reset to sign again 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.Today's Date MM slash DD slash YYYY
