Mental Health Crisis / Safety Plan Agreement

# Mental Health Crisis / Safety Plan Agreement > **Important — not medical advice.** For use by a licensed provider; verify state scope-of-practice and informed-consent rules. **Date:** ___________ **Clinician / Provider Name:** ___________ **Credential / License Number:** ___________ **Practice / Agency Name:** ___________ **Patient Name:** ___________ ("Patient") **Date of Birth:** ___________ --- ## About This Safety Plan This safety plan was developed collaboratively between the Patient and the clinician. It is a personal, practical tool — not a contract to stay alive, but a set of steps to follow when the Patient is in distress. The plan is most effective when reviewed and practiced regularly, not only in a crisis. The Patient is encouraged to share this plan with trusted support people. **This plan replaces any prior safety plan on file.** The clinician and Patient should review and update this plan at each relevant clinical visit. --- ## Step 1 — Warning Signs Warning signs are thoughts, images, moods, situations, or behaviors that may indicate a crisis is developing. **My personal warning signs are:** Warning Sign 1: ___________ Warning Sign 2: ___________ Warning Sign 3: ___________ Additional Warning Signs: ___________