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    Personal Crisis Plan

    "*" indicates required fields

    MM slash DD slash YYYY
    Patient Name*
    MM slash DD slash YYYY
    Responsible Party*
    If patient is a minor or has a legal representative or guardian, additional information is needed.
    Responsible Party*
    Guardian/Legal Representative is required to attach supporting legal documentation.

    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)
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    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.

    MM slash DD slash YYYY
     
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