Form DOC13-527 "Mental Health Safety Plan" - Washington

What Is Form DOC13-527?

This is a legal form that was released by the Washington State Department of Corrections - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 13, 2019;
  • The latest edition provided by the Washington State Department of Corrections;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOC13-527 by clicking the link below or browse more documents and templates provided by the Washington State Department of Corrections.

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Download Form DOC13-527 "Mental Health Safety Plan" - Washington

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PATIENT I.D. DATA:
(name, DOC #, birthdate)
MENTAL HEALTH SAFETY PLAN
DATE
FACILITY
UNIT (optional)
Safety Plan
List recommended actions for patient to take to stay safe (select from the list and/or add your own):
See my Primary Therapist,
, on a regular basis and follow
recommendations.
Meet with my psychiatric prescriber to discuss medications if appropriate.
If prescribed medications, take them as directed.
Attend the
therapy group so I can learn and apply some new
skills that will help me to manage my distress better.
List patient specific ideas to personalize the Safety Plan:
Additional actions:
What warning signs could you or others be looking for to show you might be thinking of suicide in the future?
What will you do when you recognize these signs?
Who can you notify if you are feeling suicidal? (Be specific)
Housing Considerations (check all that apply)
No alternate housing needs at this time
Urgent transfer to another facility for MH reasons indicated
Urgent referral to Residential Treatment Unit indicated
Routine referral to Residential Treatment Unit indicated
Other housing considerations:
Housing Unit Supervisor alert needed?
Yes
No
Comments:
Once a Safety Plan is developed and agreed to, the patient signs and dates below:
PATIENT SIGNATURE
DATE
CLINICIAN PRINTED NAME, TITLE, AND SIGNATURE
DATE
All Safety Plans must be reviewed and signed by a Clinical Supervisor:
CLINICAL SUPERVISOR PRINTED/STAMPED NAME, TITLE, AND SIGNATURE
DATE
State law and/or federal regulations prohibit disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by law.
DOC 13-527 (11/13/2019)
Page 1 of 1
MENTAL HEALTH: Reference
Classification category 1
PATIENT I.D. DATA:
(name, DOC #, birthdate)
MENTAL HEALTH SAFETY PLAN
DATE
FACILITY
UNIT (optional)
Safety Plan
List recommended actions for patient to take to stay safe (select from the list and/or add your own):
See my Primary Therapist,
, on a regular basis and follow
recommendations.
Meet with my psychiatric prescriber to discuss medications if appropriate.
If prescribed medications, take them as directed.
Attend the
therapy group so I can learn and apply some new
skills that will help me to manage my distress better.
List patient specific ideas to personalize the Safety Plan:
Additional actions:
What warning signs could you or others be looking for to show you might be thinking of suicide in the future?
What will you do when you recognize these signs?
Who can you notify if you are feeling suicidal? (Be specific)
Housing Considerations (check all that apply)
No alternate housing needs at this time
Urgent transfer to another facility for MH reasons indicated
Urgent referral to Residential Treatment Unit indicated
Routine referral to Residential Treatment Unit indicated
Other housing considerations:
Housing Unit Supervisor alert needed?
Yes
No
Comments:
Once a Safety Plan is developed and agreed to, the patient signs and dates below:
PATIENT SIGNATURE
DATE
CLINICIAN PRINTED NAME, TITLE, AND SIGNATURE
DATE
All Safety Plans must be reviewed and signed by a Clinical Supervisor:
CLINICAL SUPERVISOR PRINTED/STAMPED NAME, TITLE, AND SIGNATURE
DATE
State law and/or federal regulations prohibit disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by law.
DOC 13-527 (11/13/2019)
Page 1 of 1
MENTAL HEALTH: Reference
Classification category 1