Mental health crisis management plan Worksheet

Personal information

Full Name

D.O.B

Address

Emergency Contacts

Name

Relationship

Contact No.

Medical Information
Doctor/Therapist Name and Contact		Clinic/Hospital Name and Contact
Diagnosis		Current Medication(s)
Ongoing treatments		Dosage
Problematic symptoms		Any known allergies/side effects of any medications
Medical History
Past hospitalizations
Reasons
Treatment provided
Treatment Preferences: Treatments that you want to allow and avoid

References

Mental Health America. (n.d.). BE PREPARED: CRISIS PLAN WORKSHEET

National Alliance on Mental Illness. (n.d.) Mental Health Crisis Planning.

You can download more Mental Health worksheets here.

Please note: There may be a more up-to-date and editable version of this worksheet available here which may be more suitable to present to clients if you are a therapist or to use in a classroom as a teacher or guidance counsellor.