Depression and Bipolar Support Alliance New Jersey



 

DBSA New Jersey
P.O. Box 707
Montclair, NJ 07042
(973) 744-5230

General Information:
 margoatwell@msn.com

Plan for Life – Sample

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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):
__________________________________        __________________________________
__________________________________        __________________________________

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Copyright © 2004 Depression and Bipolar Support Alliance New Jersey

 

webmaster: w2xau@arrl.net

Thanks CM