Part 1 What I’m like when I’m feeling well

Part 2 Signs that I need help from others

If I have several of the following signs, my supporters or people I choose as named in this document need to take over responsibility for my care and make decisions in my behalf based on the information in this plan. Thinking to do what is best.

Part 3 Supporters

If this plan needs to be activated, I want the following people to take over for me. This is only to be done if I can't think and its necessary.

Name Connection/role Phone number

Specific Tasks for this Person

Name Connection/role Phone number

Specific Tasks for this Person

Name Connection/role Phone number

Specific Tasks for this Person

Name Connection/role Phone number Specific Tasks for this Person

I do not want the following people involved in any way in my care or treatment: Name I don’t want them involved because: (optional)

Name I don’t want them involved because: (optional)

Name I don’t want them involved because: (optional)

Name I don’t want them involved because: (optional)

Settling Disputes Between Supporters

If my supporters disagree on a course of action to be followed, I would like the dispute to be settled in the following way:

Part 4 Medications / Supplements / Health Care Preparations Physician ____________________ Psychiatrist ______________________

Other Health Care Providers

Pharmacy ___________________ Pharmacist ________________________ Allergies ______________________________________________________________

Insurance Information ___________________________________________________ Medication / Supplement / Health Care Preparation Dosage

Purpose

Medication / Supplement / Health Care Preparation Dosage

Purpose

Medication / Supplement / Health Care Preparation Dosage

Purpose

Medication / Supplement / Health Care Preparation Dosage Purpose

Part 5 Treatments and Complementary Therapies

Treatment/Complementary Therapy

When and how to use this treatment/complementary therapy

Treatment/Complementary Therapy

When and how to use this treatment/complementary therapy Treatment/Complementary Therapy

When and how to use this treatment/complementary therapy

Part 6 Home Care / Community Care / Respite Center

If possible, follow the following care plan:

Part 7 Hospital and other Treatment Facilities If I need hospitalization or treatment in a treatment facility, I prefer the following facilities in order of preference Name Contact Person Phone Number I prefer this facility because

Name Contact Person Phone Number

I prefer this facility because

Name Contact Person Phone Number

I prefer this facility because

Avoid using the following hospital or treatment facilities Name Reason to avoid using

Part 8 Help from others Please do the following things that would help reduce my symptoms, this would make me more comfortable and keep me safe. I think to create some better environmental effect.

I need (name the person) __________________ to (task) _____________________

I need (name the person) __________________ to (task) _____________________

I need (name the person) __________________ to (task) _____________________

I need (name the person) __________________ to (task) _____________________

I need (name the person) __________________ to (task) _____________________

Do not do the following. It won’t help and it may even make things worse.

Part 9 Inactivating the Plan The following signs or actions indicate that my supporters no longer need to use this plan.

I developed this plan on (date) ______________ with the help of ___________________ Any plan with a more recent date supersedes this one. Signed ______________________________ Date __________________ Witness _____________________________ Date __________________ Witness _____________________________ Date __________________

Attorney _____________________________ Date __________________

Durable Power of Attorney ____________________________________

Substitute for Durable Power of Attorney ___________________________

Any Personal Crisis Plan developed on a date, this is after the dates listed above takes precedence over this document. So I think this is safe as a point if allowed for by those whom want to work if available.

For further information on developing a Crisis Plan:

Mary Ellen Copeland PO Box 301, West Dummerston, VT 05357
Phone: (802) 254-2092
Fax: (802) 257-7449
info@mentalhealthrecovery.com
www.mentalhealthrecovery.com.