Appendix

_{From: Borderline personality disorder: An information guide for families. (© 2009 CAMH)}

Family crisis information sheet

 

Emergency personal contacts

 

Primary contact

Name_______________________________________________________

Home phone_____________________ Work phone__________________

Cell phone_______________________ E-mail______________________

 

Back-up contact

Name_______________________________________________________

Home phone_____________________Work phone___________________

Cell phone______________________ E-mail________________________

 

Treatment providers

Family doctor

Name

Phone

Case manager/therapist/substance use or mental health counsellor

Name 1_____________________________________________________

Phone______________________________________________________

Name 2_____________________________________________________

Phone______________________________________________________

 

Hospital/treatment centre or crisis team

Name_______________________________________________________

Phone_______________________________________________________

 

Medications

 

Current medications

Medication name 1_____________________________________________

Dose_______________________    Time of day_____________________

Medication name 2_____________________________________________

Dose__________________________Time of day_____________________

Medication allergies

The following medications were ineffective and/or caused serious side-effects

Medication name 1________________________________________________

Side-effects______________________________________________________

Medication name 2________________________________________________

Side-effects______________________________________________________

Suggestions for helping in a crisis or emergency:   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Adapted from: A Family Guide to Concurrent Disorders, p. 176–177, Toronto, Centre for Addiction and Mental Health

• Print