Menu for a Crisis Card or Joint
Crisis Plan
This
menu is to help you decide what you would like on your crisis card or joint
crisis plan. Some sections can be
simply filled in by you if you want them included. Elsewhere you may want to
select an item but wait to discuss the details with your treatment team at your
crisis planning meeting.
You
can include as much or as little information as you wish. Whatever you have
chosen or agreed at your crisis planning meeting will then be made up into your
own personal card or plan.
It
is important that your Crisis Card or Joint Crisis Plan is kept up to date. If
you feel that it needs to be updated at any time please contact your treatment
team.
Please tick
which of the following you would like on your crisis card or plan. Please
provide details if at all possible.
My name ................................................................
Address ................................................................
................................................................
Tel no. ................................................................
GP's name ................................................................
Address ................................................................
................................................................
Tel no. ................................................................
Consultant's name ................................................................
Address ................................................................
................................................................
Tel no. ................................................................
CPN's
name ................................................................
Address ................................................................
................................................................
Tel no. ................................................................
€ Social
Worker's name ................................................................ Address ................................................................
................................................................
Tel no. ................................................................
€ Other
(please name) ................................................................ Address ................................................................
................................................................
Tel no. ................................................................
If there
is someone you would like to be called in a crisis, please tick the following
paragraph and ask this person (your nominee) if they would be willing to help
and support you in an emergency. This person could be a relative, a friend, or
an advocacy worker. It would be helpful to invite them to be present at your
crisis planning meeting when you discuss your crisis card or joint crisis plan
so that they can understand what you would want done in an emergency.
€ "If I appear to anybody to be experiencing
"mental health" difficulties that require decisions to be taken
either against my wishes or in the absence of my agreement then I
request that my nominee, below, be contacted immediately, informed of what is
happening and requested to attend as a matter of urgency. My nominee is:"
Name ......................................................................................
Address ......................................................................................
......................................................................................
Tel no: Home...................................Work...................................
Current Care
and Treatment Plan
Please tick
which of the following you would like on your crisis card or plan. You may want
to fill in the details yourself or you can discuss them with your treatment
team at your crisis planning meeting.
€ My
mental health problem or diagnosis
................................................................................................................
€ Physical illnesses or allergies eg. diabetes,
sickle cell, epilepsy, allergic to penicillin
................................................................................................................
€ My Current Care/Treatment Plan Here you can include details such as regular arrangements
to see your psychiatrist, CPN or social worker, plans to attend a day centre, plans
for rehousing or for greater support in the community
.....................................................................................................................
...............................................................................................................................................................................................................................................................................................................................................................
.....................................................................................................................
€ Current
Medication & dosage
................................................................................................................
...............................................................................................................................................................................................................................................................................................................................................
€ Circumstances
that may lead to me becoming unwell or have done in the past This may
help you, or a relative, friend or nominee to recognise when you are becoming
unwell and need help, or help prevent this happening. eg. being on my own
at weekends, forgetting to take my medication
.....................................................................................................................
...............................................................................................................................................................................................................................................................................................................................................................
€ What
happens when I first start to become unwell
This
may help you, or a relative, friend or nominee to recognise the first signs
that you are becoming unwell and need help. eg. not sleeping, becoming
restless, feeling suspicious, voices becoming louder
.....................................................................................................................
...............................................................................................................................................................................................................................................................................................................................................................
€ Treatments or other things that have been
helpful during crises or relapses in
the past
...............................................................................................................................................................................................................................................................................................................................................................
.....................................................................................................................
€ Treatments or other things that have not been
helpful during crises or relapses in the past
...............................................................................................................................................................................................................................................................................................................................................................
.....................................................................................................................
Care in a
Crisis
Here you can
make plans in advance for the care or treatment you would prefer in a crisis.
What I
would like to be done when I first start to become unwell Here you can
describe what you want done when you first become unwell, to help prevent you
from becoming fully unwell eg. make an appointment to see your keyworker or
psychiatrist urgently, start some medication that you know has helped you in
the past.
.....................................................................................................................
...............................................................................................................................................................................................................................................................................................................................................................
€ Preferred
treatment or social care during a crisis or relapse Here you can
describe what you want done if you do become fully unwell. This may be helpful
if it is difficult to make decisions for yourself when you are fully unwell.
..........................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
€ Specific refusals regarding treatment during a crisis or
relapse Here you can describe what you do not want done if you become
fully unwell.
................................................................................................................
...............................................................................................................................................................................................................................................................................................................................................
€ Circumstances in which I would wish to be admitted to
hospital for treatment This may be useful if you recognise that there
are times when it would be helpful to be treated in hospital, but find it difficult to accept that you need
this help when you are becoming unwell.
.....................................................................................................................
...............................................................................................................................................................................................................................................................................................................................................................
Practical
Help in a Crisis
If you live
alone you may wish to have the following tasks undertaken should you have to be
admitted to hospital. You will need to give details of who you would like to
carry out these tasks and where they can be contacted. You will
need to ask their permission, give them information such as the phone numbers
to cancel services, and may wish to leave them a spare set of keys to your home
in case of an emergency.
€ If I am admitted to hospital please contact the person
named below and ask them if they would carry out the following tasks for me.
Name ......................................................................................
Address ......................................................................................
......................................................................................
Tel no: Home...................................Work...................................
tick whichever are required
€ check my home is secure. ie. doors
locked, cooker and fires turned off.
€ dispose of perishable food
€ cancel services eg. milk deliveries,
paper deliveries, home help.
€ water plants or garden
€ look after my pet
€ let my work (or college or day centre)
know
€ other (please describe the task you
need carried out)
.................................................................................................
€ If I am admitted to hospital I would like the following
arrangements for my children/dependent relative If you have
young children, or an elderly/disabled relative at home you may want to give
details about who you would like to look after them if you are in hospital. For
children you may want to say whether you would like them to continue at school,
nursery or with the childminder, and what you would like them to be told.
.....................................................................................................................
...............................................................................................................................................................................................................................................................................................................................................................
€ Other information I would like to be known or taken into
account
eg.
special diets, people I would or would
not like to be told,
people I would or would not like to
visit me
.....................................................................................................................
...............................................................................................................................................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
Agencies or people that I
would like to have copies of this card or agreement
(please tick)
€ myself
€ treatment
team
€ emergency
clinic
€ GP
€ my
nominee
€ other
(please name) .......................................................................
Date of Crisis Planning
Meeting ......................
Present at meeting:
|
Name |
Role or
profession
eg.friend,
relative, keyworker/CPN |
|
|
|
PRiSM,
Institute of Psychiatry, De Crespigny Park, London, SE5 8AF. Tel. 020-7848-0732/0714