Plan for Life – Sample

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 Choice Hospital:	________________________________________
Address:	________________________________________
Phone:	________________________________________

My Health Insurance Information (attach photocopy of insurance card)
Insurance Company/HMO:	_______________________________________
Address:	_______________________________________
Phone:	_______________________________________
Policy Number:	_______________________________________

My DBSA Support Group
Group Name:	________________________________________
Contact Name:	________________________________________
Phone:	________________________________________
Additional Information
Allergies/Medical Conditions:	________________________________________
	________________________________________
Prescribed and over-the-counter medications I'm currently taking (if any):
________________________________________________________________________
________________________________________________________________________
If I start to think about suicide, I will contact these trusted family member or friends (in order of priority):
__________________________________        __________________________________
__________________________________        __________________________________