Client Name: ______________________________ Phone: ____________________________________ Address: __________________________________, _____________________, ____, _________
Names of people to contact in an emergency:
Name: _____________________________________
Daytime phone: ____________________________ Evening phone: ____________________________
Address: __________________________________, _____________________, ____, _________
Name: _____________________________________
Daytime phone: ____________________________ Evening phone: ____________________________
Address: __________________________________, _____________________, ____, _________
Name: _____________________________________
Daytime phone: ____________________________ Evening phone: ____________________________
Address: __________________________________, _____________________, ____, _________
I, ______________________________________, agree that I will not attempt to harm myself either accidentally or on purpose. I agree that if at anytime I begin to experience thoughts about harming myself, I will call my therapist at (760-913-8426).
If I am unable to reach my therapist, I agree to call a family member, friend, or the 24-hour crisis hotline at the National Hope Line (suicide prevention) number at 1-800/SUICIDE (1-800-784-2433) or the Access & Crisis line at 888-724-7240.
I have read and understand the terms and conditions stated above. I agree to fully abide by this No Self-Harm Agreement.
Printed Name of Patient: ___________________________________________
Signature of Patient: ____________________________ Date: _____________
Printed Name of Therapist: Crystal Duncan, LCSW CA61763
Signature of Therapist: ____________________________ Date: _____________
Names of people to contact in an emergency:
Name: _____________________________________
Daytime phone: ____________________________ Evening phone: ____________________________
Address: __________________________________, _____________________, ____, _________
Name: _____________________________________
Daytime phone: ____________________________ Evening phone: ____________________________
Address: __________________________________, _____________________, ____, _________
Name: _____________________________________
Daytime phone: ____________________________ Evening phone: ____________________________
Address: __________________________________, _____________________, ____, _________
I, ______________________________________, agree that I will not attempt to harm myself either accidentally or on purpose. I agree that if at anytime I begin to experience thoughts about harming myself, I will call my therapist at (760-913-8426).
If I am unable to reach my therapist, I agree to call a family member, friend, or the 24-hour crisis hotline at the National Hope Line (suicide prevention) number at 1-800/SUICIDE (1-800-784-2433) or the Access & Crisis line at 888-724-7240.
I have read and understand the terms and conditions stated above. I agree to fully abide by this No Self-Harm Agreement.
Printed Name of Patient: ___________________________________________
Signature of Patient: ____________________________ Date: _____________
Printed Name of Therapist: Crystal Duncan, LCSW CA61763
Signature of Therapist: ____________________________ Date: _____________
