Relapse Prevention Plan

What I know about my mental illness

a. Diagnosis: ________________________________________________________________

b. Symptoms: _______________________________________________________________

________________________________________________________________________

c. Course: __________________________________________________________________

d. Treatment: ________________________________________________________________

Wellness Toolbox

o In my experience, these are the things that support my wellness:

o This is what carries a sense of meaning or significance for me, this is what inspires me and
reminds me of my values:

o These are some things that I would like to try to see if they would support my wellness:
My Baseline: What am I like when I am well?

o When I feel well, I am............

Daily Maintenance Plan: What I need to do to maintain my wellness

o I need to do this every day to keep myself feeling as well as possible.

o This is what I need to do, less often than every day, to keep my overall wellness and sense
of wellbeing

o These are the things that I know I need to do to sustain my wellness, but for some reason
do not do them

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Triggers

o Recognize: What triggers me? (i.e., thoughts, situations, person, memories, etc.)

o Action Plan: What can I do about my triggers?

o How do I cope with my triggers when they occur? How do I prevent things from getting

worse?

o What do I do when I have a rough day?

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Early Warning Signs

Note: Early warning signs are the subtle signs of changes in our thoughts or feelings or behavior,
which indicates that you may need to take action to avoid a worsening of your condition or
situation.

o Recognize: What are my early warning signs?

o Action Plan: What can I do when I recognize my early warning signs?

When Things Start Breaking Down or Getting Worse

o Recognize: This is how I think and feel, and how I behave when the situation has become
uncomfortable, serious or even dangerous.

o Action Plan: When things have progressed this far caring for myself is my top priority. What
can I do to reduce these difficult and unpleasant experiences, and prevent things getting
worse?

When It Gets Too Bad

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Describe how others would know that they need to take over some or full responsibility for your
care and make decisions on your behalf, what are you like?

When it gets too bad, I .............

Social Support

List those people you want to take over for you when the symptoms you listed above are obvious.

1. Name: 3. Name:
Contact details: Contact details:
Connection/Role: Connection/Role:

2. Name: 4. Name:
Contact details: Contact details:
Connection/Role: Connection/Role:

When my supporters disagree amongst themselves, this is how I would like the dispute settled:

List those people you DO NOT want to take over for you when the symptoms you listed above are
obvious.

1. Name: Reason (optional):

2. Name: Reason (optional):

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If I am in danger…

What do you want your supporters to do for you?

Treatment and Medications

Physician details

o Physician: _____________________________________________________
Contact details: ______________________________________________

o Physician: _____________________________________________________
Contact details: ______________________________________________

o Psychiatrist: ____________________________________________________
Contact details: ______________________________________________

List the medications you are currently taking and why you are taking them. Include the name of
who prescribes them.