Safety Contract

Safety Contract

Aspire Wellness Center
Name of client

First Name Last Name
Date of Birth

Month Day Year
Date
Email
example@example.com
I agree to follow this contract. I will not hurt myself in any physical way if I am feeling sad, down, depressed, anxious, or otherwise. Also, I will not hurt anyone else physically, including my therapist or psychiatrist, if I am feeling frustrated, angry, or otherwise. I will immediately (within the hour) call or tell someone to let them know how I am feeling, including the following people:
Name

First Name Last Name
Phone Number

Area Code Phone Number
Name

First Name Last Name
Phone Number

Area Code Phone Number
Name

First Name Last Name
Phone Number

Area Code Phone Number
I am also aware of resources I can access in case of emergency, such as 911, my nearest hospital, or my nearest Mobile Crisis Center

Baltimore county- 410-931-2214

Baltimore city-410-433-5175

Howard County -410-638-5248
Signature of Client/Parent or Gaurdian

Clear
Name

First Name Last Name
Date

Month Day Year
Date
Signature of Clinician

Clear
Name

First Name Last Name Credentials
Date

Month Day Year
Date
Should be Empty: