Post on 03-Apr-2018
transcript
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WELLNESS RECOVERY
ACTION PLAN
A system for monitoring, reducing and eliminatinguncomfortable or dangerous physical symptoms
and emotional feelings
developed by
Mary Ellen Copeland, MS, MA
Author of
The Depression Workbook:A Guide to Living with Depression and Manic Depression
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Living Without Depression and Manic Depression:A Guide to Maintaining Mood Stability
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Winning Against Relapse:A Workbook of Action Plans for Reoccurring Health and Emotional Problems
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The Adolescent Depression Workbook~~~~~~~~~
The Worry Control WorkbookRevised 7/3/02
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DAILY MAINTENANCE LIST
What Im like when I am feeling all right:
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DAILY MAINTENANCE LIST
Things I need to do for myself every day to keep myselffeeling all right:
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DAILY MAINTENANCE LIST
Additional things I might need to do (or that would begood to do):
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TRIGGERS
Things that, if they happen, might cause an increase inmy symptoms:
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TRIGGER RESPONSE
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TRIGGERS
Action Plan -- Things that I can do if my triggers come upto keep them from becoming more serious symptoms:
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EARLY WARNING SIGNS
Some early warning signs that others have reportedand/or I have observed:
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EARLY WARNING SIGNS
Things I must do if I experience early warning signs:
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EARLY WARNING SIGNS
Things I can do if they feel right to me:
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WHEN THINGS ARE BREAKING DOWN
Signs/symptoms that indicate that things are gettingworse:
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WHEN THINGS ARE BREAKING DOWN
Action Plan Things that can help reduce my symptomswhen they have progressed to this point:
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CRISIS PLAN
This crisis plan is written when I am well. The purpose is to instruct
others about how to care for me when I am not well. This keeps mein control even when it seems like things are out of control.
Part 1 What Im like when Im feeling well:(reference Daily Maintenance List)
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CRISIS PLAN
Part 2 SYMPTOMS that indicate that others need to takeover full responsibility for my care and make decisionson my behalf:
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CRISIS PLAN
Part 3 These are my SUPPORTERS, the people who Iwant to take over for me when the symptoms I listed inPart 2 come up:
Name __________________________________________________________
Relation to me ___________________________________________________
Phone number ___________________________________________________
Role I want this person to play and/or task(s) I need him/her todo_______________________________________________________________
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Name __________________________________________________________
Relation to me ___________________________________________________
Phone number ___________________________________________________
Role I want this person to play and/or task(s) I need him/her to do
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Name __________________________________________________________
Relation to me ___________________________________________________
Phone number ___________________________________________________
Role I want this person to play and/or task(s) I need him/her to do
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CRISIS PLAN
Part 3 (continued)
Name __________________________________________________________
Relation to me ___________________________________________________
Phone number ___________________________________________________
Role I want this person to play and/or task(s) I need him/her to do
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Name __________________________________________________________
Relation to me ___________________________________________________
Phone number ___________________________________________________
Role I want this person to play and/or task(s) I need him/her to do
_______________________________________________________________
The people I do not want involved in any way and why:
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CRISIS PLAN
Part 4 Medications/Supplements
Medications/supplements I am currently taking and why I amtaking them:
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Medications/supplements I prefer to take if medications oradditional medications become necessary, and why I choosethem:
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CRISIS PLAN
Part 4 continued
Medications/supplements that are acceptable to me ifmedications become necessary and why I choose them:
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Medications/supplements that must be avoided and reasonswhy:
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CRISIS PLAN
Part 5 Treatments
Treatments that help reduce my symptoms and when theyshould be used:
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Treatments I want to avoid and why:
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CRISIS PLAN
Part 6 Community Plan
What can be put into place in order for me to stay at home orin my community and still get the care I need:
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CRISIS PLAN
Part 7 Treatment Facilities
Treatment facilities where I prefer to be treated or hospitalizedif that becomes necessary:
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Treatment facilities I want to avoid and why:
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CRISIS PLAN
Part 8 Help From Others
Things that others can do for me that would help reduce mysymptoms or make me more comfortable:
What I need/would like done Who Id like to do it
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CRISIS PLAN
Part 8 continued
Things others might do, or did in the past, that would not/didnot help and/or might make symptoms worse:
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CRISIS PLAN
Part 9 Inactivating the Crisis Plan
Symptoms, lack of symptoms or actions that indicate that mysupporters no longer need to use this Crisis Plan:
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I ______________________________________ consider this document to be part of my treatment,
and therefore authorize my treatment provider _________________________________________
to share information contained in this Wellness Recovery Action Plan with the following hospitals,
agencies and/or individuals in the event of an emergency and/or hospitalization:
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Signature _________________________________ Date ____________
Witness/Supporter ______________________________ Date ____________
Witness/Supporter ______________________________ Date ____________
Witness/Supporter ______________________________ Date ____________
Witness/Supporter ______________________________ Date ____________
Witness/Supporter ______________________________ Date ____________
Notary
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