Developing a Prevention Plan

Telephone Number:

Date of most recent self-injury*:

Preferred method of self-injury*:

Suggested Prevention Steps Derived From User*:
Describe Possible Steps You Can Agree To Follow.
Step 1:
Step 2:
Step 3:
Step 4:
Step 5:

Helpful People You would be willing Call*:

Name: Relation: Phone:

Name: Relation: Phone:

Name: Relation: Phone:

You agree to above steps and calls before starting any self injury action* ?

Yes
No

Leave a note in the guest book if you would like more contact from this page or other users*. No one will use this to interfere, nor will the info be 'resold'.

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First name
Last name
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country

Date of this plan*:

Remarks:

Prepared by*: