Patient Safety F Plan a Template
1 SOKA thee Feelig Monee
2 —0appi0 “Ges nats rep Bigee forte agri
3. LOST’ iWiérest \Schndoj_ d’ Friends
1. _Woscvy up 4 fona\ ides
2. “Taxe tong Y Sawer
3. rope deve A Conn
ee Fee mune
1. Name__Fri@nva #1 Phone _SS5-i23-1234
2, Name__fanns\w4 wade FEL Phone S$S- $VLe~ 54,
3. Place, Lok “pave TWO Vesna, uch 4, Place. “Temple
1. Name Schnanl _Counse\os Phone_W27 “123-1240.
2. Name_Qyrtygr, Phone_}J8~ 4-164)
3. Name_ “ROCMA.C Phone_]247-4)2~ S71,
1. ClinicianName_ Dt. Qanvis Phone_28/4-S4iy 4418;
Clinician Pager or Emergency Contact #
2. Clinician Name_Or. LOnds\icle Phone_IX\-242.- 22° W
Clinician Pager or Emergency Contact #
3. Local Urgent Care Services. . Boke
Urgent Care Services Address 2% pwn Ss,
Urgent Care Services Phone 5%) = VC \— S72
4, Suicide Prevention Lifeline Phone: 1-800-273-TALK (8255) ff CriiS yeh WAL
1. mods a Ited Up - Marner adinaisiecs 4 Yop. ey
ee =
‘ef nemo barb ean Ga. own, ped vn wes Pein te or, Ho ation cf heey an ng ay eet
oth rst farms. ou ater srs bude wesc
The one thing that is most important to me and worth living for is:
Aemu. 2 Dwi UNG cae cls, EAC,