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    Personal Crisis Plan

    "*" indicates required fields

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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.
    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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