CRISIS MANAGEMENT PLAN - A FORM TO FILL OUT FOR WHEN CRISES ENTER YOUR WORLD

We all experience times in our life when we are in a crisis, be it emotional distress or physical issues that are beyond a point we ourselves can control or deal with alone. Having a Crisis Management Plan is one of the best ways for you to be prepared for crises that will rise in your life from time to time.

What you will find here is a form that you can print up as many times as you need to fill out as a have on hand manual of what to do when you are unable to think clearly, too stressed to focus or too sick to speak for yourself. I have one of the forms for medical crises and one for emotional crises should they arrive in my life and I cannot speak for myself. I carry a copy of each in my purse so when a crisis does arrive, my voice is heard through the plan.

When you have completed filling out your form, it is best to get your doctor in charge of your medical care to be a witness to it and to give him/her a copy to put into your file for their reference should it be needed. If, like me, you have more than one doctor, each doctor should have a copy of your plan(s). I strongly suggest making a plan for both an Emotional Crisis and for Medical Crisis and ensuring ALL of your doctors/counselors have a copy of each for their own reference. By doing this, you ensure that you will get the desired treatments preferable to you and just as importantly, to not get treatments you do not agree with. A good example of the use of one of these forms is for such a case as heart failure: would you want the medical staff to try and keep you alive or would you prefer to have a DNR - DO NOT RESUSCITATE (which should also be in your legal will). By your doctors - plural - having a copy of your plan, your wishes are more likely to be carried out than those of the medical staff caring for you. In Brownies, Girl Guides, Beavers and Boy Scouts, we are taught to BE PREPARED. I believe in that motto and hope you find the following form I have made to be useful should you ever need it to be enforced. Be as clear and exact as you possibly can, stating what is and is not acceptable. Have your Medical File on hand, listing all your Medical Conditions, Medications you take, Why you take the medications and When you take them. List your allergies to medications and anything else, your address, health card number, insurance company and information...anything you consider relevant to YOUR Crisis Plan. No two plans will be alike. This is YOUR LIFE you are preparing for so make sure it is as detailed as possible and update the information on it at least every 2 months. Medication changes, new allergies, etc., all need to be updated so you do not get any adverse reactions. Copy and paste the doctor, medication and any other information you need more of. We all have at least 2 doctors - family and dental. Some have many more, so make sure you copy and paste the necessary field as often as you yourself need it there. Do likewise for the Medication Field. It requires accuracy to ensure you get what makes you remain in a good state of health.
Best wishes and good health to you.

THE FORM

MY CRISIS MANAGEMENT PLAN

FULL NAME:

FULL ADDRESS:

PHONE NUMBER:

HEALTH CARD NUMBER:

INSURANCE COMPANY INFORMATION:

DOCTORS:

NAME:
SPECIALTY:
PHONE NUMBER:
ADDRESS:

NAME:
SPECIALTY:
PHONE NUMBER:
ADDRESS:

NAME:
SPECIALTY:
PHONE NUMBER:
ADDRESS:

OTHER PEOPLE TO CALL IN CASE OF AN EMERGENCY:

NAME:
RELATION:
PHONE NUMBER:
ADDRESS:

NAME:
RELATION:
PHONE NUMBER:
ADDRESS:

NAME:
RELATION:
PHONE NUMBER:
ADDRESS:

ALLERGIES:

MEDICAL CONDITIONS:

MEDICATIONS:

MEDICATION:
TIME OF DAY TO TAKE IT:
WHAT IT IS FOR:
PRESCRIBING DOCTOR:

MEDICATION:
TIME OF DAY TO TAKE IT:
WHAT IT IS FOR:
PRESCRIBING DOCTOR:

MEDICATION:
TIME OF DAY TO TAKE IT:
WHAT IT IS FOR:
PRESCRIBING DOCTOR:

THE FOLLOWING ARE THE STEPS I WILL MAKE WHEN I FEEL I AM IN CRISIS:

5 PEOPLE/PLACES I CAN CALL IN CRISIS
1.
2
3.
4.
5.

5 THINGS THAT MAKE ME HAPPY
1.
2.
3.
4.
5.

5 THINGS I CAN DO TO HELP MYSELF
1.
2.
3.
4.
5.

THINGS WHICH ARE A DANGER TO ME THAT I SHOULD PUT AWAY
1.
2.
3.
4.
5.

5 THINGS THAT HAVE HELPED ME IN THE PAST
1.
2.
3.
4.
5.

5 THINGS I WILL NOT DO WHEN I AM IN CRISIS
1.
2.
3.
4.
5.

Should all the above fail, I commit to going, by whatever means I need, to the local hospital’s Emergency Department and being seen by an Emergency Physician.

I swear to uphold this plan by signing my name here and by having a sign as a witness to this Plan.

NAME:

WITNESS:

DATE:

***ADD ANY OTHER DATE YOU FEEL IS IMPORTANT TO YOU FOR ANY MEDICAL STAFF TO KNOW TO SUPPORT AND GET YOU BACK TO FULL HEALTH. EMERGENCY CONTACTS, ETC.