ࡱ> %` gbjbjNN D,,# b b b 8 ^!;64"L%(%%%%,&&B&r5t5t5t5t5t5t5$o7h95]'%%''5%%5---'%%r5-'r5---%z" Nb v(-2 60;6-}:v)`}:-}:-R&>&,-&$&R&R&R&55*R&R&R&;6''''D>$ >5 Mid-Valley Behavioral Care Network Effective Date  FORMTEXT       Share with your mental health provider and FAX to Roger at 503-585-4989 (for PCC file) PERSONAL ACTION / CRISIS PREVENTION PLAN CLIENT INFORMATIONName  FORMTEXT      Date of Birth  FORMTEXT      County of Residence  FORMTEXT      Phone(s)  FORMTEXT      Support Persons: (family, advocate, peer support)( Mark who you want called in a crisisName  FORMTEXT      Relationship  FORMTEXT      Phone  FORMTEXT       FORMCHECKBOX Name  FORMTEXT      Relationship  FORMTEXT      Phone  FORMTEXT       FORMCHECKBOX Name  FORMTEXT      Relationship  FORMTEXT      Phone  FORMTEXT       FORMCHECKBOX  MEDICAL INFORMATIONCounselor / Case Manager  FORMTEXT      Phone  FORMTEXT      Agency  FORMTEXT      Phone  FORMTEXT       If you are taking mental health medications, who prescribes them? Name  FORMTEXT      Phone  FORMTEXT      Primary Care Physician  FORMTEXT      Phone  FORMTEXT      Person who has a list of your current medications  FORMTEXT      Medications that have been helpful in emergencies  FORMTEXT      Medications to avoid and why  FORMTEXT      Allergies / adverse medical effects  FORMTEXT      Mental health conditions  FORMTEXT      Substance use issues  FORMTEXT      Medical conditions  FORMTEXT       FORMCHECKBOX  I have completed a Declaration for Mental Health TrDFdfz|~ιzsgR=R)h=Xh8B* CJOJQJ^JaJph)h=XhE0KB* CJOJQJ^JaJphhNcKhE0K>*CJaJ hE0K>*CJ=jhum5>*B* CJOJQJU^JaJmHnHphu>jhumhO\5>*B* CJOJQJU^JaJph)hum5>*B* CJOJQJ^JaJph2jhum5>*B* CJOJQJU^JaJph hE0KCJhoM5CJ$\hE0K5CJ$\> @ 2 Xukdt$$Iflh*+ t062:2 s44 laytPw- $IfgdPw-$a$gd5$a$gd8$a$gd8gdE0K  !0*gdoM Ffg> @ ^ ` b d źźůzoU@)h9o5>*B* CJOJQJ^JaJph2jh9o5>*B* CJOJQJU^JaJphh]"h>mH sH h.^hG=CJaJ%h.^hG=B* CJOJQJaJphh.^hG=5CJaJh(cJh8CJaJh^5CJ,\aJ,h-)5CJ,\aJ,h8hE0K5CJ,\aJ,&hNcKh=X5CJOJQJ\^JaJ/h=XhE0K5B* CJOJQJ\^JaJph " $ . 0 4 \ ^ r t v ƧƜƃcƧƘ_ƃ?Ƨ_;hMO>jh9ohO\5>*B* CJOJQJU^JaJphh5>jh9ohO\5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJphh>h]"h>mH sH =jh9o5>*B* CJOJQJU^JaJmHnHphu2jh9o5>*B* CJOJQJU^JaJph>j h9ohO\5>*B* CJOJQJU^JaJph2 4 vmm $IfgdPw-kd$$Iflh0( * m t062:2 s44 laytPw- " $ & ( 0 t ~ ѱ掆~w~ia]YU5>jh9ohO\5>*B* CJOJQJU^JaJphh2[hMhYshYsCJ aJ  jhYshYsCJ aJ h*#hMh*#hM6h hM6h5=jh9o5>*B* CJOJQJU^JaJmHnHphu>jh9ohO\5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJph2jh9o5>*B* CJOJQJU^JaJph $ r vma $$Ifa$gd8 $IfgdPw-kdl$$Iflh0*) t062:2 s44 laytPw-r t  @ vmmmm $IfgdPw-kd$$Iflh0* t062:2 s44 laytPw-      ƳƚzƳƚZƳF'jhJ5B* OJQJU^Jph>jh9ohO\5>*B* CJOJQJU^JaJph>j$h9ohO\5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJphh2[$hh2[5B* OJQJ^Jph2jh9o5>*B* CJOJQJU^JaJph=jh9o5>*B* CJOJQJU^JaJmHnHphu : < > @ B L N b d f p r t ¯xX9&$hh9o5B* OJQJ^Jph=jh9o5>*B* CJOJQJU^JaJmHnHphu>j:h9oh9o5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJph2jh9o5>*B* CJOJQJU^JaJphh9oh2[$hh2[5B* OJQJ^Jph'jhJ5B* OJQJU^Jph3jhJh]X5B* OJQJU^JphhJ5B* OJQJ^Jph@ B t  PGGG> $IfgdPw- $IfgdO\kd`$$Iflh\ P(*D H7 E t062:2 s44 laytPw-  ѱ{[G7h9o5B* OJQJ^Jph'jh9o5B* OJQJU^Jph>jh9oh9o5>*B* CJOJQJU^JaJphh9o$hh9o5B* OJQJ^Jph=jh9o5>*B* CJOJQJU^JaJmHnHphu>jh9oh9o5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJph2jh9o5>*B* CJOJQJU^JaJph    0 2 4 > @ B \ ^ r t v ѾkL,>j$ h9oh9o5>*B* CJOJQJU^JaJph=jh9o5>*B* CJOJQJU^JaJmHnHphu>j h9oh9o5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJph2jh9o5>*B* CJOJQJU^JaJphh9o$hh9o5B* OJQJ^Jph'jh9o5B* OJQJU^Jph3jxhJh9o5B* OJQJU^Jph  B PGGG> $IfgdPw- $IfgdO\kd$$Iflh\ P(*D H7 E t062:2 s44 laytPw-v ƳƚzƳfVj h9ohO\5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJphh9o$hh9o5B* OJQJ^Jph2jh9o5>*B* CJOJQJU^JaJph=jh9o5>*B* CJOJQJU^JaJmHnHphu PKB $IfgdPw-gd5kd` $$Iflh\ P(*D H7 E t062:2 s44 laytPw-  <>RTV`bprѷcѷCc?ѷh('>jF h9oh9o5>*B* CJOJQJU^JaJph=jh9o5>*B* CJOJQJU^JaJmHnHphu>j h9oh9o5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJph2jh9o5>*B* CJOJQJU^JaJphhG=h.^hG=CJaJ%h.^hG=B* CJOJQJaJphh.^hG=5CJaJ d $IfgdPw-ukd: $$Iflh*+ t062:2 s44 laytPw-vmm $IfgdPw-kd $$Iflh0*| t062:2 s44 laytPw-ƧƣƎnƧƣjb^Ǝ>Ƨ^Ǝ>jh9oh9o5>*B* CJOJQJU^JaJphh -h -h -6h('>jh9oh9o5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJphhG==jh9o5>*B* CJOJQJU^JaJmHnHphu2jh9o5>*B* CJOJQJU^JaJph>j^h9oh9o5>*B* CJOJQJU^JaJphvm $IfgdPw-kd<$$Iflh0*| t062:2 s44 laytPw- $IfgdPw-ukd$$Iflh*+ t062:2 s44 laytPw-&(<>@JLZ\prt~ƧƣƊjƧƣƊJƧƣF>h .h .5h .>jh9oh9o5>*B* CJOJQJU^JaJph>jh9oh9o5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJphh('h -=jh9o5>*B* CJOJQJU^JaJmHnHphu2jh9o5>*B* CJOJQJU^JaJph>jh9oh9o5>*B* CJOJQJU^JaJphNvmm $IfgdPw-kd`$$Iflh0*| t062:2 s44 laytPw-vm $IfgdPw-kd$$Iflh0*| t062:2 s44 laytPw- vxLNbͭnN>jh9oh9o5>*B* CJOJQJU^JaJph>jh9oh9o5>*B* CJOJQJU^JaJph=jh9o5>*B* CJOJQJU^JaJmHnHphu>jh9oh9o5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJph2jh9o5>*B* CJOJQJU^JaJphh . $IfgdPw-ukd$$Iflh*+ t062:2 s44 laytPw- $IfgdPw-ukd$$Iflh*+ t062:2 s44 laytPw-t $IfgdPw-ukd&$$Iflh*+ t062:2 s44 laytPw-bdfpr "LNbƧƣƎnƧƣƎNƧƣƎ>jh9oh9o5>*B* CJOJQJU^JaJph>jh9oh9o5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJphh .=jh9o5>*B* CJOJQJU^JaJmHnHphu2jh9o5>*B* CJOJQJU^JaJph>jh9oh9o5>*B* CJOJQJU^JaJphtv $IfgdPw-ukd2$$Iflh*+ t062:2 s44 laytPw-$ $IfgdPw-ukd>$$Iflh*+ t062:2 s44 laytPw-$&t $IfgdPw-ukdJ$$Iflh*+ t062:2 s44 laytPw-bdfprvx\\:\<\P\ƧƣeUMKM6)h9o5>*B* CJOJQJ^JaJphUh .h .6h .5B* OJQJ^Jph3jhJh]X5B* OJQJU^JphhJ5B* OJQJ^Jph'jhJ5B* OJQJU^Jphh .=jh9o5>*B* CJOJQJU^JaJmHnHphu2jh9o5>*B* CJOJQJU^JaJph>jh9oh9o5>*B* CJOJQJU^JaJphtvb\ $IfgdPw-ukdV$$Iflh*+ t062:2 s44 laytPw-eatment. It is available at:  FORMTEXT       PERSONAL ACTION / CRISIS PREVENTION PLANNINGThe document called  Ideas to Help Spark Your Thinking  has suggestions others have found helpful.1. Some things I want from my life are:  FORMTEXT      2. Signs that I m doing OK:  FORMTEXT      3. Early signs that I m not feeling well:  FORMTEXT      4. What I can do to help myself:  FORMTEXT      5. Ways that others can help me:  FORMTEXT      6. What I don t want  What doesn t help:  FORMTEXT      7. I know I need to get help when:  FORMTEXT      In a crisis I need to know I have help with:  FORMCHECKBOX  Pets  FORMCHECKBOX  Children  FORMCHECKBOX  Transportation  FORMCHECKBOX  Other: (explain)  FORMTEXT       In a crisis situation, I will do this:  FORMTEXT      Optional: My provider or other support person agrees to do this:  FORMTEXT       FORMCHECKBOX  I would like to request a trauma survivor peer support volunteer (if you re on Oregon Health Plan) FORMCHECKBOX  I would like information about other peer support services Oregon state law allows healthcare providers to share your confidential information to the extent necessary to help you during an emergency. Oregon Revised Statutes 179.505 (4)(a)     ABOUT THIS FORM: Type only in the grey highlighted fields. Each field will expand as you type into it. The grey color will not show when the form is printed. Page  PAGE 1 of  NUMPAGES 2 P\R\T\^\`\d\f\\\\\\].]]]]ƧƣubRBRb/+h.^%h-)h.^B* CJOJQJaJphh-B* CJOJQJaJphhF&B* CJOJQJaJph%h-)hF&B* CJOJQJaJphh.^h.^56CJaJh5E5CJaJh.^h.^5CJaJhNcKh1CJaJh .=jh9o5>*B* CJOJQJU^JaJmHnHphu2jh9o5>*B* CJOJQJU^JaJph>jVh9oh9o5>*B* CJOJQJU^JaJphb\d\f\\]{{ $IfgdPw-gd5ukd$$Iflh*+ t062:2 s44 laytPw-]]^xo $IfgdPw-kdb$$Ifl0*  t062:2 s44 layt-]]]]]]]]^^ ^4^<^>^R^T^V^ɩފiT4i>jh9oh9o5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJph2jh9o5>*B* CJOJQJU^JaJph h}h}=jhPC5>*B* CJOJQJU^JaJmHnHphu>j hPChPC5>*B* CJOJQJU^JaJph)hPC5>*B* CJOJQJ^JaJph2jhPC5>*B* CJOJQJU^JaJphh5h}^^d^ $IfgdPw-ukdv$$Ifl*+ t062:2 s44 laytPw-V^`^b^f^j^l^^^^^^^^^^"_&_(_<_>_@_J_L_P_T_V_____»Ƣ»Ƣb»Ƣ>j& h9oh9o5>*B* CJOJQJU^JaJph>jh9oh9o5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJphh} h}h}h52jh9o5>*B* CJOJQJU^JaJph=jh9o5>*B* CJOJQJU^JaJmHnHphud^f^^ $IfgdPw-ukd$$Ifl*+ t062:2 s44 laytPw-^^N_ $IfgdPw-ukd$$Ifl*+ t062:2 s44 laytPw-N_P__ $IfgdPw-ukd $$Ifl*+ t062:2 s44 laytPw-________ ```&`(`*`4`6`:`|``````````ƧƣƃcƧƣƃCƧƜ>jJ#h9oh9o5>*B* CJOJQJU^JaJph>j>"h9oh9o5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJphh} h}h}h5=jh9o5>*B* CJOJQJU^JaJmHnHphu2jh9o5>*B* CJOJQJU^JaJph>j2!h9oh9o5>*B* CJOJQJU^JaJph__8` $IfgdPw-ukd!$$Ifl*+ t062:2 s44 laytPw-8`:`` $IfgdPw-ukd"$$Ifl*+ t062:2 s44 laytPw-``aa,bs $If^gdPw- $IfgdPw-ukd#$$Ifl*+ t062:2 s44 laytPw-`aaa"a$a&a*a0a:a*B* CJOJQJ^JaJph2jhPC5>*B* CJOJQJU^JaJphh@)[ h}h@)[ h}h})hS[5>*B* CJOJQJ^JaJph=jh9o5>*B* CJOJQJU^JaJmHnHphu>j%h9oh9o5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJph2jh9o5>*B* CJOJQJU^JaJphh},b.bb $IfgdPw-ukdj&$$Ifl*+ t062:2 s44 laytPw-bbbbbbbb(c*c>c@cBcƧƠs^>s>j(h9ohO\5>*B* CJOJQJU^JaJph)h9o5>*B* CJOJQJ^JaJph2jh9o5>*B* CJOJQJU^JaJph h h@)[h h@)[6h@)[ h}h@)[=jhPC5>*B* CJOJQJU^JaJmHnHphu2jhPC5>*B* CJOJQJU^JaJph>j'hPChPC5>*B* CJOJQJU^JaJph bbPc $IfgdPw-ukdl'$$Ifl*+ t062:2 s44 laytPw-BcLcNcPcRcTcpcrctcvcd@d\d^d`dbddddeBfFfƿ}v\vQKC?hwhw0JaJ hwaJhNcKh5CJaJ3j*hJh]X5B* OJQJU^Jph h@)[h@)[3j)hJh]X5B* OJQJU^JphhJ5B* OJQJ^Jph'jhJ5B* OJQJU^Jphh@)[ h h@)[2jh9o5>*B* CJOJQJU^JaJph=jh9o5>*B* CJOJQJU^JaJmHnHphuPcRcdd $IfgdPw-ukdz)$$Iflh*+ t062:2 s44 laytPw-dddDfFfJfLfPfRfVfXf\f^fg}}}}}}}}t $Ifgd^rgdwgd5ukdz*$$Iflh*+ t062:2 s44 laytPw- FfHfLfNfRfTfXfZf^f~fffggggggggggggggggggggg˻˨{{r{{{r{nhwh>zmHnHujh UhR9h CJ aJ h hR9h hh B* CJaJph%hh B* CJOJQJaJphh B* CJOJQJaJph%hh B* CJOJQJaJph(hh 5B* CJOJQJaJphhjhU ggggggggggd5$a$gd`fEkd+$$Ifl*+ t644 laytzUBPP&P1h/R :p5/ =!"#$% tDText1$$If!vh5+#v+:Vlh t065+2:2 sytPw-tDText3jD$$If!vh5 5m #v #vm :Vlh t065 5m 2:2 sytPw-jDjD$$If!vh5)5#v)#v:Vlh t065)52:2 sytPw-$$If!vh55#v:Vlh t0652:2 sytPw-jDjDjDhDe$$If!vh5D 5H57 5E#vD #vH#v7 #vE:Vlh t065D 5H57 5E2:2 sytPw-jDjDjDhDe$$If!vh5D 5H57 5E#vD #vH#v7 #vE:Vlh t065D 5H57 5E2:2 sytPw-jDjDjDhDe$$If!vh5D 5H57 5E#vD #vH#v7 #vE:Vlh t065D 5H57 5E2:2 sytPw-$$If!vh5+#v+:Vlh t065+2:2 sytPw-tDText3jD$$If!vh55|#v#v|:Vlh t0655|2:2 sytPw-tDText3jD$$If!vh55|#v#v|:Vlh t0655|2:2 sytPw-$$If!vh5+#v+:Vlh t065+2:2 sytPw-tDText3jD$$If!vh55|#v#v|:Vlh t0655|2:2 sytPw-tDText3jD$$If!vh55|#v#v|:Vlh t0655|2:2 sytPw-tDText3$$If!vh5+#v+:Vlh t065+2:2 sytPw-tDText3$$If!vh5+#v+:Vlh t065+2:2 sytPw-tDText3$$If!vh5+#v+:Vlh t065+2:2 sytPw-tDText3$$If!vh5+#v+:Vlh t065+2:2 sytPw-tDText3$$If!vh5+#v+:Vlh t065+2:2 sytPw-tDText3$$If!vh5+#v+:Vlh t065+2:2 sytPw-tDText3$$If!vh5+#v+:Vlh t065+2:2 sytPw-hDetDText3$$If!vh5+#v+:Vlh t065+2:2 sytPw-$$If!vh55 #v#v :Vl t0655 2:2 syt-jD$$If!vh5+#v+:Vl t065+2:2 sytPw-tDText3$$If!vh5+#v+:Vl t065+2:2 sytPw-tDText3$$If!vh5+#v+:Vl t065+2:2 sytPw-tDText3$$If!vh5+#v+:Vl t065+2:2 sytPw-tDText3$$If!vh5+#v+:Vl t065+2:2 sytPw-tDText3$$If!vh5+#v+:Vl t065+2:2 sytPw-tDText3$$If!vh5+#v+:Vl t065+2:2 sytPw-hDehDehDehDetDText3$$If!vh5+#v+:Vl t065+2:2 sytPw-jD$$If!vh5+#v+:Vl t065+2:2 sytPw-jD$$If!vh5+#v+:Vl t065+2:2 sytPw-tDeCheck1$$If!vh5+#v+:Vlh t065+2:2 sytPw-hDe$$If!vh5+#v+:Vlh t065+2:2 sytPw-$$If!vh5+#v+:Vl t06,5+ytzU@@@ E0KNormalCJ_HaJmH sH tH :: 5 Heading 1$@&5\DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k(No List4@4 E0KHeader  !j@j 5 Table Grid7:V04 @4 `fFooter  !.X@!. wEmphasis6] FGB_` !:[u2LMh'AB:;hi123`23qrTU  R S   l m n " # % & ( ) + , . / 0000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 @0 0 0 0 0 @0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000 0 0 0 0 0 0 0 0 0 00X00@0X00e@0X00e@0X00e@0X00e@0 @0 @0@0 XhJ@0@0@0X00&eFGB_` !:[u2LMh'AB:;hi123`23qrTU  R S   l m n " # 0000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000 0 0 0 0 0 0 0 0 0 00 00@0 @0 @0P00K~@0@0 00    v bbP\]V^_`abBcFfg !$(,479=ABDFJ2 r @  t$tb\]^d^^N__8``,bbPc?@CEGHIKg 2>D.:@KW] &28GSYamsu*08DJT`fnz%-9?t&28T`f~)/*0]io@LR  > J P  / FFFFFFFFG$FFFG$FFFG$FFFFFFFFFFFFFFFG$FFFFFFFFG$G$G$G$FFFG$G$!Text1Text3Check12 E jK1l!kK1JlK1lq9mK1l:n n t t   9*urn:schemas-microsoft-com:office:smarttagsState9*urn:schemas-microsoft-com:office:smarttagsplace 4k2E.AK^  " # # % % & & ( ) + , . / 2E.AK^    " # # % % & & ( ) + , . / 32E.AK^` !uB 3 " # # % % & & ( ) + , . / 2E.AK^ !u18KTgn&-@t&9Tg~0V_`1]p@S  S S  0 " # $ % % & ' ( * + - . 0/0.D@cwq$Nq*Rrx $ ? f F  W +[ [ -h`&8Dek|~AaN@^`CQI 6{h!Evv7 p w !S!P*"*#q$ 's'!'('G * *#*.0+6+jN+QT+,Pw-O/.0+}1l23e3DE4H4}5R9mu;G=R>/ ?@?pg?z?7@qJ@zA5EjEsE(cJE0KNcK L4LXL}LpMIMNMOdOYP R R RTKT Vk&WEX=XBX]X4Yu&[@)[/H[X \O\]]4]^V^|&_9`cc e//g&8h Th2izFbjG5JeM8|8^ 8{xAL Y`fwJ<$$YsM8:jV-) P|* .U4al@ENbV!-q=lsNvoMR<]"> /& :\VOIx0)]&g)^1zU^o{'j)4`}Ua9]+7S[x\{ MB_` !:[u2LMh'AB:;hi123`23qrTU  R S   l m # @?D/??X PP P PPPP\UnknownGz Times New Roman5Symbol3& z ArialA& Arial Narrow;Wingdings"1hnCզnCզXBզz z x4d  2QHX ?jE2"Mid-Valley Behavioral Care NetworkCheryl HenningCheryl HenningOh+'0< T`    $Mid-Valley Behavioral Care NetworkCheryl Henning,BCN crisis plan type-in form 05-2009.dotCheryl Henning2Microsoft Office Word@@d@4@4z ՜.+,0 hp   MVBCN ' #Mid-Valley Behavioral Care Network Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLNOPQRSTUVWXYZ[\]^_`abdefghijklmnopqrstuvwxyz{|}~Root Entry FData M+1Tablec}:WordDocumentDSummaryInformation(DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q