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Contract against Suicide, Self-Harm, or Harm to Others

, agree to the following:

I understand that my therapist has a legal, ethical, and professional obligation to take all practical and reasonable measures she/he considers to ensure my safety from suicide and/or self-harm. I agree that this is in my best interest and that I will cooperate with my therapist by providing honest information about any thoughts, desires, or impulses I have to hurt or kill myself.

I agree not to act on any thoughts, desires, or impulses I may have to hurt or kill myself between:

and

If, at any time, I feel unable to resist any thoughts, desires, or impulses I may have to hurt or kill myself, I agree that rather than act on hurting or killing myself, I will do one or more of the following:

  • Chat with someone: https://suicidepreventionlifeline.org/chat/
  • Text “Home” to 741741 and you can chat over text with counselor.
  • Call 911 and tell the operator that I am thinking about hurting or killing myself
  • Call my therapist at 856-547-1107 ext.
  • If I am unable to reach my therapist, I will call the Cherry Hill Twin Oaks Crisis Center at (856) 428-4357
  • If I am unable to reach the Hotline, I will call the National Suicide Prevention Lifeline at 1-800-273-8255 or chat online http://chat.suicidepreventionlifeline.org/GetHelp/LifelineChat.aspx
  • I will physically take myself to the emergency room of Kennedy Hospital Cherry Hill or the closest emergency room and tell the staff that I am thinking of hurting or killing myself.

I agree that I will either keep this contract with me, in a location where I can quickly get to it at all times while it is in force, and/or that I will copy down these telephone numbers and keep them with me while this contract is in force.