Crisis/Relapse Prevention Plan

Crisis/Relapse Prevention Plan

You will receive a copy of this form upon submission. It will be in the form of a password protected PDF. Use Password: Jadewellness1! to access.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Today's Date:

MonthDayYear
Date
Email
example@example.com
Triggers: When these things happen, I am more likely to feel unsafe or upset.

Anniversary of lossArgumentsBeing isolatedBeing stared atBeing tiredBeing told what to doBeing touchedChallenges with doctors/staff/employersContact with a particular personContact with my familyDarknessDifficulties with coworkersDifficulty with familyDifficulty with friendsDifficulty with partnerDoing work that's hard for meFeeling left outFeeling lonelyFeeling pressuredFeeling sickFinancial problemsHaving a headacheHearing voicesLack of privacyLoss of a loved oneLoud noisesNot being listened toNot following scheduleNot having controlPhysical health problemsParticular time of dayParticular time of yearPeople yellingProblems at school/workRelapseOther
Anniversary of loss (specify)
Contact with a particular person (specify)
Contact with my family (specify)
Physical Health Problems
Particular time of day
Particular time of year
Other:
Thoughts/inside warning signs: These are things i may notice just before i feel unsafe or upset.

Body achesCravings to use alcoholCravings to use drugsDecreased appetite.Feeling afraidFeeling disorientedFeeling dizzyFeeling like I don't care about myself.Feeling nervous/anxiousFeeling paranoid-others are out to get meFeeling sickHearing voicesIncreased appetiteNot enjoying things I used toNot wanting to go outside.Racing thoughtsSeeing things that aren't really there.StomachacheThoughts of hurting myselfThoughts of hurting othersWanting to destroy thingsWanting to run awayOther
Other (specify)
Outside warning signs: These are things other people may notice just before I feel unsafe or upset.

ArgumentativeBecoming very quietBeing rudeBounding legsBreathing hardCan't sit stillClenching fistsClenching teethCryingDamaging thingsEating lessEating moreGrandiose thoughtsHoarding thingsHyperactivityIsolating/avoiding peopleLaughing loudly/gigglyLoud voiceNot getting along w/ peopleNot getting out of bedNot taking care of myselfPacingParanoiaRashes/hivesRed facedRefusing to take my medicationRockingRunning awaySleeping a lotSleeping lessSwearingSweatingUncooperativeUsing alcoholUsing drugsWringing handsOther
Other (specify)
Things that help me stay better or feel more in control NOW: things that can help me calm down.

A cold cloth on faceArts and craftsBeing around othersBouncing a ballCalling familyCold water on handsCooking/bakingDancingDeep breathingDoing chores/jobsDrawingDrinking waterExercisingGoing to a movieGoing to churchHaving someone listen to me without talking too muchHelping other peopleHugging a stuffed animalHumorListening to musicLying downMaking a collageMeditatingPlaying cardsPrayerReading a bookSinging/hummingSitting in a rocking chairSitting with staffSpeaking with my therapistTalking a break in my roomTaking a walkTalking with a peerTalking with friendsTalking with someone I trustUsing the gymVideo gamesVolunteeringWatching TVWriting in a journalYogaOther
Calling family
Talking with a peer
Talking with friends
Talking with friends
Talking with someone I trust
Others
Things that make me feel worse: These are things that do not help me calm down or stay safe:

Being aloneBeing around peopleBeing bossed aroundBeing disrespectedBeing ignoredBeing reminded of the rulesBeing told "I understand"Being touchedHumor/jokingLoud tone of voiceNot being listened toNot talking to a mentorPeople getting in my spacePeople hovering over mePeople nagging mePeople picking on meOther
Not talking to a mentor
Other
When I notice triggers or warning signs, I will take action to prevent things getting worse. By doing the following things: (Please list three things)
When I notice triggers or warning signs, I will take action by calling the following three people (include three names and phone numbers)
When I notice I'm getting upset, I'd like them to help prevent things from getting worse by: (include 3 suggestions)
When I handle a stressful time without doing anything to make it worse, I can reward myself safely by: (include 3 things you find rewarding).
Sometimes a crisis cannot be prevented. For me, a true crisis might look like the following Behaviors, Feelings and Thoughts.

If I'm experiencing a crisis, I would like the following plan to be followed:

If it is during business hours please call

JAD Wellness Center: 412-380-0100

If it's not during business hours, please call

Forbes regional hospital: 412-858-2321

UPMC Mercy Hospital Emergent Detoxification needs: 412 232 8800

In the past these things have worked for me in a crisis (list up to three things)
Things that didn't work in the past were (list up to three things)
I will share this plan with the following people: (list three people)
PDF Crisis Plan Password will be Jadewellness1!

Yes
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