I, __________________________________, agree to stay calm and allow my family member to do one or more of the following in the event of a bipolar episode:
a) inform me if I am in an episode.
b) call 911 if I am a danger to myself, a danger to others, am gravely disabled and/or destroying property. My family member will advise 911 about what is happening and that I am experiencing a bipolar episode. My family member may have to leave my presence to call 911 if they are unsafe.
c) leave my presence if I am safe alone, until I am able to calm down.
d) go over our "What Works" list together.
e) assist me with my "What Works" list. IE., help to de-escalate me.
f) call my Dr. and/or Therapist or a local crisis line.
g) drive me to a place recommended by my family member such as the hospital, crisis unit, etc.
h) advise me to take any medication recommended by my Dr.
My Signature Date
Family Member Date