Relapse Prevention Plan Form

Relapse Prevention Plan Form
Personal Information
Name
First NameLast Name
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Program Counselor Name
Triggers & Warning Signs
What situations trigger cravings or relapse?
Early warning signs I notice in myself
Trigger categories
Other
Describe situations where relapse is most likely
Time of day/week when I feel most vulnerable
“If I feel close to relapse, I will… blanks "
Coping Strategies
Write down your strategy
Support System
Person I can contact when looking for support:
First NameLast Name
Person's contact number
Please enter a valid phone number.Format: (000) 000-0000.
My Emergency Contact Person
First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
🚨 Emergency Plan In this area you will make a plan list instead of the action you wrote in first section: “If I feel close to relapse, I will…"
Motivation & Goals
This part is underrated but powerful, you can do this.
Staying sober/recovered matters to me because blanks
Short-term goals
Long-term goals
Write down your daily habits that support your recovery such as sleep / exercise / eating :
Should be Empty:

Personal Information