Personal Crisis Plan

Today's Date

Patient Name*

First Name Middle Initial Last Name

Email*

Date of Birth*

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)

Responsible Party 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.

Today's Date

Personal Crisis Plan

Personal Crisis Plan

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.

New Patients: Request Initial Appointment

Existing Patients: Update Your Information

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