Client Safety Contract Form

* Required Information

I (client), hereby contract with Lily Health and Wellness Center Telepsychiatry Mental Health Provider/Clinician, that I will take the following actions if I feel suicidal…

I will NOT attempt suicide.
I will call someone, please provide name and telephone #
If I do not reach Dr. Linda Allibalogun or my assigned provider, I can either call my therapist or phone any of the following services:

Names/Agencies:

National Suicide Prevention Hotlines 1-800-SUICIDE (784-2433) or 1-800-273-TALK (8255) http://www.aamentalhealth.org/pr_warmline. 410-768-5522
Disaster Distress (Helpline Offers Immediate Crisis Counseling) 1-800-985text "TalkWithUs" to 66746 1-800-985-5990 or test "Habianos" to 66746 (Spanish)
I will further seek support from any of the following people: Provide names and phone numbers

Name

Phone Number

Name

Phone Number

If none of these actions are helpful or not available, I will go to the ER at one of the following: Provide potential Hospital name, Address, and Phone below:

Hospital Name

Address

Phone

If I am unable to get help or I am unable to go to the hospital, I will call 911 and request help.

Client Signature

Clear

Date

I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.