It may be a good idea to split the first question into two parts. Copy and paste the full first sentence and put a colon. Answer this part. Then, copy and paste the second sentence and place a colon. Replace “these” with “the following”. Answer this part. See example below:

The following are symptoms or behaviors I typically exhibit when escalating toward a mental health crisis:

excessive worrying or fear (about ...), feeling excessively sad or low, bouts of crying, lack of pleasure when engaging in activities, isolating/withdrawing, confused thinking, problems concentrating, prolonged or intense bouts of anger, feeling restless -- like I can't sit still, difficulty interacting or engaging with others, exhaustion, sleeping too much or too little, eating more or less than usual, changes in libido, feeling as though I am in a dream, feeling as though my body is not real, other dissociative symptoms, delusions (about …), experiencing voices that don’t exist in objective reality (saying … – do they give commands?), experiencing visuals that don’t exist in objective reality (of … – shadows or more detailed images?), experiencing times where I have full conviction that these perceptions or thoughts are true, increased paranoia, increased DOC cravings, increased substance use/abuse, increased ailments without a clear medical cause (e.g. stomach/GI issues, joint pain, headaches, dizziness, rapid heart rate, chest pain, difficulty walking, chronic pain, etc.), thoughts of wishing I wasn’t born, increased SI, developing a suicide plan, increased self harm urges, increased self harm events, inability to fulfill daily responsibilities, calling in sick to work more frequently, making up excuses to not have to see friends, things that I would normally be able to handle cause a great deal of distress (e.g. someone cancelling plans), if the previous symptom applied - how long does this distress last? Rumination? Does distress increase with time? (what people refer to as “spiraling”), intense fear of weight gain, thinking about food more frequently, restricting food intake, increased binging/purging, obsessive thoughts around weight (number), preoccupation with weight (mine or others), obsessive thoughts (about …), increased compulsions (e.g. counting, hand washing, symmetry, cleanliness, avoiding illness, hoarding, turning light switches on/off a number of times, holding my breath, etc.), increased feelings of guilt or shame, inflated sense of self (grandiosity), doing things I wouldn’t normally do because the consequences/dangers don’t come to mind (e.g. excessive shopping, gambling - try providing specific examples from lived experience), increased impulsivity/risk taking, decreased hygiene (not showering, brushing my hair, or brushing my teeth every day, not doing laundry, not grocery shopping, etc.)*

Does the declarant have different mood states or diagnoses? Try listing them separately:

depressive episode: ....., manic episode: ....

*paraphrased from CANAMI website

If I exhibit any of the FOLLOWING symptoms or behaviors, an evaluation may be needed regarding whether I am capable of making mental health care decisions:

No known symptoms.

If other: provide examples that have led to hospitalization in the past. For mania - think about what led to that point. For delusions/psychotic episodes - think about how self-awareness goes (Are there episodes of decreased insight – even for 30 seconds – before a prolonged episode?)

Not maintaining a consistent sleep schedule, not exercising, increased stress (what kind? Social? Academic? Work?), isolating, withdrawing from friends and family, suddenly stopping prescribed medications, substance use/abuse, family conflict, relationship turmoil, homelessness, loss of a job, medical/health problems, not attending therapy sessions, avoidance of stressors (not taking the elevator if I have a fear of elevators, placing pots around the room or sleeping in shoes in case of an intruder, etc. )

Consider picking specific symptoms and what helps with those symptoms. Coping strategies for one symptom may not be useful for others.

Anxiety: grounding exercises (5, 4, 3, 2, 1), orienting to the room, breathing exercises, meditation, being reminded of what I need to address right now and what I can shelve for a later time, exercise, etc.

Depression: engaging in activities, spending time with one or two close friends, establishing a manageable routine/schedule, exercise, light therapy, etc.

Dissociation: taking a cold shower, holding a plastic bag with ice (not recommended for individuals with self-harm tendencies), walking on gravel with my shoes off, NOT BEING TOUCHED, etc.

Mania: exercise in moderation (to channel restlessness from a mixed episode), dark therapy (black out curtains or light filtering glasses), sticking to a regulated sleep schedule (even if I can’t sleep), sticking to a regular daytime schedule, limiting travel, limiting use of social media (having a friend monitor posts/emails to a boss prior to posting/sending), etc.

Psychosis/Delusions: do not try to convince me that my beliefs are wrong, do not try to play into my beliefs (e.g. don’t say, “yes, they are after us” … ), distraction (e.g. puzzles, art therapy), avoiding triggers (e.g. cell phones, tv – this is highly individual), maintaining a regular schedule, clear and concise communication (explain to me why you are making the decisions you are making regarding my care – avoid being too wordy or using large words if I’m experiencing issues with cognition), listen to my concerns (don’t dismiss me or be curt with me), etc.

Eating disorder: don’t comment on my weight or my appearance, don’t draw attention to me when I am eating, offer a variety of food choices, sit with me for 30 minutes after a meal, don’t discuss exercise with me or exercise in front of me, offer distracting activities, etc.

Compulsions: exercise to distract myself, don’t assume that I should conquer all compulsions at once, don’t try to reason with me, take things at my pace, etc.

SI and self harm: develop a safety plan, attend the facility’s AA meetings for self harm (treating it as an addiction/compulsion can be useful), build rapport with me – be someone I can talk to or reach out to, etc.

For all: treat me with respect and listen to my concerns.

Therapies that have worked well in the past: DBT, CBT, psychodynamic, somatic experiencing, EMDR, etc.

My cognitive symptoms start to diminish, my sleeping returns to a healthy schedule, I am taking care of myself and my hygiene without being asked, I am engaging with others, I am doing activities or hobbies that I enjoy (chess, painting, etc.), I demonstrate that I can engage in treatment planning with my provider, etc.

List dosages! Specify between PRN (as needed) and daily maintenance medications. For PRNs, list symptoms and medications so providers know when each medication is useful.

Here is a list of psychotropic medications. Not all medications are listed. Seeing a list may be useful for jogging your memory of medications you have tried in the past.

Antidepressants:

● Fluoxetine (Prozac)

● Paroxetine (Paxil)

● Sertraline (Zoloft)

● Citalopram (Celexa)

● Escitalopram (Lexapro)

● Fluvoxamine (Luvox)

● Duloxetine (Cymbalta)

● Venlafaxine (Effexor)

● Desvenlafaxine (Pristiq)

● Milnacipran (Savella)

● Levomilnacipran (Fetzima)

● Clomipramine (Anafranil)

● Imipramine (Tofranil)

● Amitriptyline (Elavil)

● Desipramine (Norpramin)

● Nortriptyline (Pamelor)

● Amoxapine (Asendin)

● Doxepin (Sinequan)

● Phenelzine (Nardil)

● Tranylcypromine (Parnate)

● Isocarboxazid (Marplan)

● Selegiline (Emsam)

● Vilazodone (Viibryd)

● Vortioxetine (Trintellix)

● Bupropion (Wellbutrin)

● Mirtazapine (Remeron)

● Nefazodone (Serzone)

● Trazodone (Desyrel)

Antipsychotics:

● Cariprazine (Vraylar)

● Aripiprazole (Abilify)

● Quetiapine (Seroquel)

● Olanzapine (Zyprexa)

● Risperidone (Risperdal)

● Paliperidone (Invega)

● Ziprasidone (Geodon)

● Clozapine (Clozaril)

● Asenapine (Saphris)

● Lurasidone (Latuda)

● Haloperidol (Haldol)

● Chlorpromazine (Thorazine)

● Perphenazine (Trilafon)

● Trifluoperazine (Stelazine)

Mood Stabilizers:

● Lithium

● Valproate (Depakote)

● Lamotrigine (Lamictal)

● Carbamazepine (Tegretol)

● Oxcarbazepine (Trileptal)

● Topiramate (Topamax)

Stimulants:

● Amphetamines (Adderall)

● Dexamphetamine (Dexedrine)

● Lisdexamfetamine (Vyvanse)

● Desmethylphenidate (Focalin)

● Methylphenidate (Ritalin/ Concerta)

● Modafinil (Provigil)

● Armodafinil (Nuvigil)

● Atomoxetine (Strattera)

Anti-anxiety / Sleeping Medications:

● Buspirone (Buspar)

● Hydroxyzine (Vistaril)

● Diphenhydramine (Benadryl)

● Doxylamine (Unisom)

● Melatonin

● Gabapentin (Neurotin)

● Propranolol (Inderal)

● Prazosin (Minipress)

● Clonazepam (Klonopin)

● Alprazolam (Xanax)

● Lorazepam (Ativan)

● Diazepam (Valium)

● Temazepam (Restoril)

● Oxazepam (Serax)

● Chlordiazepoxide (Librium)

● Zolpidem (Ambien)

● Eszopiclone (Lunesta)

● Zaleplon (Sonata)

● Ramelteon (Rozerem)

● Suvorexant (Belsomra)

Other Treatments:

● ECT

● TMS

● Ketamine

● Light therapy

Consider, do you live alone or with someone else? Can the person they live with offer support? Is there somewhere they would be able to stay with somebody who would provide the support they desire? What about a Peer Support & Respite Center of Georgia?

Are there outpatient services you would like to use: PHP, IOP?

Peer Support & Respite Centers of Georgia

“Georgia's Peer Support and Respite Centers are peer-run alternatives to traditional mental health day programs and psychiatric hospitalization.

Each of the five Peer Support and Respite Centers has respite rooms available to citizens of Georgia, available 24 hours a day, year-round. The three or four respite rooms at each Center are free of charge and can be occupied by a peer overwhelmed by life challenges who feels they would benefit from 24/7 peer support, for up to seven nights, every 30 days.” -GMHCN

Augusta Peer Recovery & Respite Center

1720 Central Avenue

Augusta, GA 30904

Phone: 706-426-4030

Email: augusta@gmhcn.org

Bartow County Peer Recovery & Respite Center

201 North Erwin Street

Cartersville, GA 30120

Phone: 770-276-2019

Email: bartowcounty@gmhcn.org

Colquitt County Peer Recovery & Respite Center

417 2nd Street SE

Moultrie Georgia 31768

Phone: 229-873-9737

Email: colquittcounty@gmhcn.org

Decatur Peer Recovery & Respite Center

444 Sycamore Drive

Decatur Georgia 31768

Phone: 404-371-1414

Email: decatur@gmhcn.org

White County Peer Recovery & Respite Center

46 Knaus Drive

Cleveland Georgia 31768

Phone: 706-865-3601

Email: whitecounty@gmhcn.org

Emergency medications/PRNs (as needed medications), etc.

Names of specific hospitals, treatment facilities that offer TMS in their outpatient programs, private treatment facilities, I have _____ insurance but would authorize to be treated by a facility charging out of network rates for _____ days/weeks. If my stay surpasses that duration, I wish to be transferred to an in network facility, I have _____ insurance and wish to only consent to being treated at an in network facility, etc.

State Facilities

GA Regional Hospital ATL

3073 Panthersville Road

Atlanta, GA 30034

GA Regional Hospital at Savannah

1915 Eisenhower Drive

Savannah, GA 31406

West Central GA Regional Hospital - Columbus, GA

3000 Schatulga Road

Columbus, GA 31907

East Central Regional Hospital - Augusta, GA

3405 Mike Padgett Hwy

Augusta, GA 30906

Crisis Stabilization Units

Advantage Crisis Stabilization Unit

195 Miles Street

Athens, GA 30601

Avita Crisis Stabilization Unit

4331 Thurmond Tanner Parkway

Flowery Branch, GA 30542

DeKalb CSB Crisis Stabilization Unit

450 Winn Way

Decatur, GA 30030

Floyd Crisis Unit

1 Woodbine Ave

Rome, GA 30165

Gateway Crisis Stabilization Unit

121 Burgess Road

Brunswick, GA 30222

Hope’s Corner Child & Adolescent Crisis Stabilization Unit

756 Woodbury Road

Greenville, GA 30222

John’s Place Crisis Stabilization Unit

4 West Altman Street

Statesboro, GA 30458

Phoenix Point Adult Crisis Stabilization Unit

940-C GA Highway 96

Warner Robins, GA 31088

Polk Residential Treatment Unit

80 Water Oak Drive

Cedartown, GA 30125

Quentin Price, MD Crisis Stabilization Unit

118 Thomas Lane

Dublin, GA 31021

River Edge Crisis Service Center

60 Highway 22 West

Milledgeville, GA 31061

Second Seasons Adult Crisis Stabilization Unit

122 Gordon Commercial Drive

LaGrange, GA 30240

Serenity Behavioral Health Systems Crisis Stabilization Unit

3421 Mike Padgett Highway

Augusta, GA 30906

St. Francis Hospital Bradley Center

2000 16th Avenue

Columbus, GA 31901

St. Illa Crisis Stabilization Program

3455 Haris Road

Waycross, GA 31503

View Point Health Adolescent Crisis Stabilization Unit

2591 Candler Road

Decatur, GA 30032

View Point Health Adult Crisis Stabilization Unit

175 Gwinnett Drive, Suite 260

Lawrenceville, GA 30346

Whitfield Treatment Whitfield Treatment Services

900 Shugart Rd

Dalton, GA 30720

Some Private Residential Facilities in the ATL Area

Skyland Trail

1961 N Druid Hills Rd

Atlanta, GA 30329

Phone: 404-315-8333

Southern Live Oak Wellness

1535 Mt. Vernon Rd

Dunwoody, GA 30338

Phone: 770-238-2674

Peachtree Wellness Solutions

100 Governors Trce

Suite 109-110

Peachtree City, GA 30269

To find more information about long term residential facilities, visit:

https://www.psychologytoday.com/us/treatment-rehab/georgia?category=long-term-30-days-residential

To find more information about short term residential facilities, visit:

https://dbhdd.georgia.gov/locations

Frightened, claustrophobic, distressed at losing my phone/access to communicate with my support system, combative, relieved, etc.

See “The following techniques may be helpful in de-escalating my crisis:” section

I am someone who identifies as transgender – to create a supportive recovery environment, use my preferred pronouns as follows:

I am someone who identifies as LGBTQIA+ and I would like to participate in group therapy for LGBTQIA+ folks and have a provider sensitive to my specific needs

Only if I am experiencing catatonia, only if I haven’t responded to high doses of my preferred medications after a trial period of one month, etc.

Consider listing certain types of therapies that have worked well in the past (DBT, CBT, psychodynamic, empirically validated treatments, EMDR, somatic experiencing, equine therapy, hypnotherapy, etc.)

I consent to Ketamine therapy, I consent to TMS, etc.

This question is optional.

I am someone who identifies as transgender – to create a supportive recovery environment, use my preferred pronouns as follows:

I am someone who identifies as LGBTQIA+ and I would like to participate in group therapy for LGBTQIA+ folks and have a provider sensitive to my specific needs

As a member of ____ religion, I adhere to these food restrictions:

As a member of ____ religion, I cannot take psychotropic medications and prefer interventions such as TMS, EMDR, and therapy.

I prefer _____ religion based therapy.

I prefer treatment with secular (non-religious) therapy.

Should I report that I am physically or sexually assaulted, I consent to a forensic medical examination. If I report that the assault occurred within a facility, I would then like to be transferred to another facility ASAP.

I have children and should I be hospitalized, they should stay with _____ who can be contacted at this number: _____

I have limited English proficiency and would prefer a provider who is bilingual.

I have _____ insurance but would authorize to be treated by a facility charging out of network rates for _____ days/weeks. If my stay surpasses that duration, I wish to be transferred to an in network facility.

I have _____ insurance and wish to only consent to being treated at an in network facility.

I wish to consent to being transferred to a long term facility in ____ state.

I wish to only be treated within the state of Georgia, where this directive will be honored.

I suffer from diabetes, epilepsy, etc. and here is how to help me if I have an episode:

Medication specific statements:

I am a person who is sensitive to SSRIs/SNRIs, and for me, they are known to induce mixed states and manic episodes. I do not consent to being treated with SSRIs/SNRIs under any circumstance.

As benzodiazepines are known to be addictive, I do not consent to take that class of medication for more than 6 days in a row. Should I require the medications to be prescribed again, I require a period of 21 days without these medications before restarting them as a PRN.

I am a poor metabolizer of psychotropic medications (see GeneSite testing). As such, I am highly sensitive to these medications. Should a new medication be prescribed, I need to be started on a half of the lowest-dose pill no more than once daily. I require a week to pass to allow for medication adjustment before the dose is increased, if it is deemed necessary.

I experience bouts of low blood pressure. I decline to take any medication whose frequent side effects include lowering blood pressure. Should I faint after starting a new medication, I require that I am taken off of this medication immediately.

****Under no circumstances do I consent to taking medications simultaneously that have moderate to severe known drug-drug interactions. This statement supersedes anything I have written under the medication section. If I am consenting to alternate decisions being made on my behalf, I require that all medications be checked for possible drug-drug interactions****