Plan for Life Sample

Print this page and add your personal information to create your own Plan For Life.

My Contact Information
Name:  
Address:  
Day Phone:   Evening Phone:  
Cell/other Phone:  
Employer:  
 
My Doctor’s Contact Information
Doctor’s Name:
Address:
Office Phone:   Emergency Phone:  
Pager/other Phone:
If my doctor is not available, contact these medical professionals:   
 
 
 
My Health Care Information
Preferred Hospital:
Address:
Phone:
2nd ChoiceHospital:
Address:
Phone:
 
Medications:
 
Allergies to/intolerance of any medication:
 
 
Insurance or Medicaid information:
 
 
 
Support Information

Things that might trigger an episode, such as life events, travel, physical illness, or work stress

 

Warning signs such as talking very fast, paranoia, lack of sleep, slowed down movement, excessive alcohol or drug use

 

Things people can say that are calming and reassuring

 

 

Things people should do in crisis such as take away car keys and lock up anything dangerous such as weapons and medications

 

 

Things emergency staff can do, such as explain things, talk slowly, observe personal space, or write things

 

 

Reasons life is worthwhile and recovery is important