ANTI-SUICIDE CONTRACT

Anti-suicide contract
Name
Name
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Last
Address
Address
City
State/Province
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Section

I further understand that if my counsellor, ___________________________ , determines that
I am in serious danger of hurting or killing myself, my right to confidentiality is
waived, and my counsellor will make any necessary telephone calls for my own
protection. I therefore authorise my counsellor to contact my emergency contacts,
in case of emergency.
1. I agree that if I have a bad time and feel that I might hurt or kill myself, I will
immediately call _______________, who is my _____________. I will also call one of
the Suicide/trauma Hotlines listed below:
o Company Wellness Solutions Trauma Line: 0800014818
o SADAG Suicide Crisis Line: 08000 567 567
o LifeLine Suicide Crisis Helpline: 08000 12 13 14
o Go to the emergency room at my nearest hospital.
o Call 10111
o SADAG Mental Health Line: 011 262 6396
1. I agree that these conditions are part of my counselling contract with my
counsellor and are effective immediately and indefinitely

Contacts

First contact Name & Surname
First contact Name & Surname
First
Last
Second contact Name
Second contact Name
First
Last