No Self Harm Contract Form PDF Details

In the realm of mental health support and crisis prevention, the No Self Harm Contract form serves as a crucial tool in fostering a commitment to safety and life-affirming behaviors among individuals struggling with the urge to harm themselves. Originating from A Counseling Center, P.C., this contract is a formal agreement between a client and their counseling service provider, designed to actively involve the client in their own safety plan. By signing the contract, the individual acknowledges their current situation and explicitly agrees to several key commitments: abstention from all forms of self-harm, including suicide and self-mutilation, contacting their counselor prior to any self-harming actions, seeking help whenever the compulsion arises, and making use of provided emergency contact numbers in times of crisis. The inclusion of specific clauses and emergency contacts, such as police and abuse hotlines, underscores the comprehensive nature of the agreement. It aims not only to prevent acts of self-harm but also to establish a support network that encourages individuals to reach out before a crisis escalates. This contract emphasizes the critical role of continuous engagement and communication with mental health professionals, illustrating a shared responsibility towards healing and recovery.

QuestionAnswer
Form NameNo Self Harm Contract Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessafety contract for self harm, contract for safety form, no suicide contract pdf, contract for safety agreement

Form Preview Example

A COUNSELING CENTER, P.C.

NO SELF-HARM CONTRACT

 

Last Name

 

First Name

Middle Initial

 

 

 

 

 

 

 

 

Street

City

State

Zip

 

 

 

 

 

 

 

 

Phone

DOB

Age

Marital Status

 

 

 

 

 

 

 

 

Emergency Contact

Phone

Guardian

Phone

 

 

 

 

 

 

 

 

Psychiatrist

Phone

Referral Source

Phone

 

 

 

 

 

 

 

 

Counselor

 

 

Phone

 

 

 

 

 

 

 

 

AGREEMENT ONE:

 

 

 

 

 

I ___________________________ being fully aware of my situation do

hereby completely

 

agree to abstain from all self-harm including suicide and self-mutilation as long I am not fully discharged from all services at A Counseling Center, P.C.

AGREEMENT TWO:

I ___________________________ being fully aware of my situation do hereby completely

agree to contact my counselor at A Counseling Center, P.C. in person or by phone before I engage in any form of self-harm including suicide and self-mutilation as long I am not fully discharged from all services at A Counseling Center, P.C.

AGREEMENT THREE:

I ___________________________ being fully aware of my situation do hereby completely

agree to obtain help and assistance whenever I feel the compulsion, strong desire, or need to harm myself in anyway including suicide, self-mutilation, and by accident as long as I am not fully discharged from all services at A Counseling Center, P.C.

AGREEMENT FOUR:

I ___________________________ being fully aware of my situation do hereby completely

agree that I am aware of the 24-hour phone numbers listed below and that I will use them whenever the need or occasion arises as long as I am not fully discharged from all services at A Counseling Center, P.C. I know I can call A Counseling Center, P.C. (402) 573-7277 and page my counselor or any one of the other counselors in an emergency situation through the voice mail by following the voicemail prompts. Other 24-hour phone numbers include: Police 911; Domestic Abuse (800) 523-3666; Child Abuse and Adult Abuse (800) 652-1999.

__________________________________________________________________________________________

Client’s SignatureDate Signed

__________________________________________________________________________________________

Witness’s Signature

Date Signed

 

 

 

 

Copyright © 2000-4 by Kevin Everett FitzMaurice

www.kevinfitzmaurice.com

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So as to finalize this document, make sure that you enter the right details in each and every area:

1. To start with, when filling in the safety contract for self harm, start out with the form section that has the next blank fields:

Part no. 1 of filling out self harm contract

2. Your next step is usually to submit all of the following blank fields: AGREEMENT TWO I being fully aware, AGREEMENT THREE I being fully, and AGREEMENT FOUR I being fully.

Step # 2 of filling out self harm contract

3. The next part is straightforward - fill out all of the form fields in AGREEMENT FOUR I being fully, Clients Signature, Date Signed, Witnesss Signature, Date Signed, and Copyright by Kevin Everett in order to finish this process.

Find out how to complete self harm contract step 3

Always be very attentive when filling out Witnesss Signature and Copyright by Kevin Everett, because this is the part in which a lot of people make a few mistakes.

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