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)Responsible Party Signature*Today's Date MM slash DD slash YYYY
