NO HARM CONTRACT

NO HARM CONTRACT
I, the client Full name* agree NOT to kill myself, attempt to kill myself, or cause any harm to myself at any time.
- I agree to get rid of anything that I could use to kill myself, including but not limited to guns, other weapons, pills etc.
- In the event of an emergency, such that I am in serious danger of hurting myself or killing myself, I agree to dial 082911 or go to the nearest hospital emergency room for immediate assistance.
- I further understand that if my counsellor, Liesel Swartz, determines that I am in serious danger of hurting or killing myself, my right to confidentiality may be waived, and my counsellor, Liesel Swartz, will make any necessary telephone calls for my own safety. I therefore authorise my counsellor to contact the following people, in case of an emergency:
Name*

First NameLast Name
Relationship to me
I agree that if I have a difficult time and feel that I might hurt or kill myself, I will immediately call Full name*. Who is my Relationship to me* .
I will also call one of the Suicide Hotline listed below:
- Life Line: 011 422 4242 or 0861 322 322
- Suicide Crisis Helpline: 0800 567 567
I agree that these conditions are part of my counselling contract with my counsellor and are effective immediately and indefinitely.
I, Full name* hereby confirm, on this day, Date* that I have read, understood and agree to the above statements.
Signature*

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