No Self Harm Contract Form PDF Details

Self-harm is a difficult issue to confront, but it’s unfortunately something that many people struggle with daily. Coping with self-harming behaviors can be a long and challenging journey full of highs and lows, so having the right support system in place is imperative. One way to provide extra reinforcement when attempting to stop self- harming behavior is through a "No Self Harm Contract." This type of agreement agrees that an individual will make their best effort not to engage in any form of self harm for a particular period of time and/or under certain circumstances. Crafting this sort of contract should be done carefully as it impacts safety and health decisions; however, using one can be incredibly beneficial if used correctly. In this blog post we'll discuss why creating a no self harm contract form can play an important role in therapeutic recovery from coping mechanism such as self harm. Let's dive into how you can create your own!

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

How to Edit No Self Harm Contract Form Online for Free

Using PDF files online can be very simple with our PDF editor. You can fill in safety contract for self harm here painlessly. In order to make our editor better and more convenient to work with, we constantly develop new features, bearing in mind feedback coming from our users. Starting is effortless! Everything you need to do is adhere to the next simple steps down below:

Step 1: Click the "Get Form" button above. It will open up our editor so you can start completing your form.

Step 2: As soon as you launch the PDF editor, you will see the document made ready to be filled in. Aside from filling out different fields, you might also do other things with the PDF, particularly writing your own textual content, editing the original text, inserting illustrations or photos, putting your signature on the document, and a lot more.

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.

Step 3: Prior to finishing this file, you should make sure that all blanks have been filled out properly. When you believe it's all good, click “Done." Create a free trial account at FormsPal and gain immediate access to safety contract for self harm - downloadable, emailable, and editable inside your FormsPal cabinet. FormsPal guarantees your information confidentiality with a protected system that never saves or distributes any private data provided. You can relax knowing your documents are kept safe whenever you work with our service!

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