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‘s Impulse Control Log

 
Time & What Would Self-
Thoughts Location Situation Feelings (3)
Date Injury Accomplish?
I  was  by  myself  thinking  about   Depressed,  
9:00  pm  
I  hate  myself.   My  bedroom   a  negative  comment  someone   Embarrassed,   Distract  me  from  pain?  
5/15/13  
made.   Lonely  
 
 
 
         
 
 
 
 
 
 
         
 
 
 
 
 
         
 
 
 
 
         
 
 
 
 
         
 
 
Impulse Control Log - side 2
 

What Am I Trying to How did I communicate or cope


Extra Notes
Communicate? (3) with my thoughts and feelings?

I’m  scared.   I  wrote  in  my  journal  


I  was  able  to  make  it  though  the  night  without  
I’m  upset.   I  called  a  friend.  
harming  myself!  
Help!  I  don’t  know  what  to  do.   I  talked  to  my  mom.  
 
 
   
 
 
 
 
   
 
 
 
 
   
 
 
 
 
   
 
 
 
 
   
 
 
 

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