Crisis Plan
When I am feeling well, I am (describe yourself when you are feeling well):
The following symptoms indicate that I am no longer able to make decisions for myself; that I am
no longer able to be responsible for myself or to make appropriate decisions.
When I clearly have some of the above symptoms, I want the following people to make decisions
for me, see that I get appropriate treatment and to give me care and support:
I do not want the following people involved in any way in my care or treatment. List names and
(optional) why you do not want them involved:
Preferred medications and why:
Acceptable medications and why:
Unacceptable medications and why:
Acceptable treatments and why:
Unacceptable treatments and why:
Home/Community Care/Respite Options:
Preferred treatment facilities and why:
Unacceptable treatment facilities and why:
What I want from my supporters when I am experiencing these symptoms:
What I don't want from my supporters when I am experiencing these symptoms:
What I want my supporters to do if I'm a danger to myself or others:
Things I need others to do for me and who I want to do it:
How I want disagreements between my supporters settled:
Things I can do for myself:
I (give, do not give) permission for my supporters to talk with each other about my symptoms and
to make plans on how to assist me.
Indicators that supporters no longer need to use this plan:
I developed this document myself with the help and support of:
Signed: ________________________________________Date: ____________________
Attorney: _______________________________________Date: ____________________
Witness: _______________________________________Date: ____________________
Witness: _______________________________________Date: ____________________
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