Relapse Prevention Plan

Collaborative form to document relapse triggers, warning signs, coping strategies, and support resources to help prevent relapse.

Consent and Submission Details

• This plan was developed collaboratively with the patient
  Confirm that the patient participated in creating this plan.
• Consent to document relapse prevention information
  I consent to documenting the information I provide for care planning and follow-up. This may include sensitive health information (PII/PHI) and will be handled according to applicable privacy and confidentiality requirements.
• Preferred contact method
  Optional. Use only if needed for follow-up.
• What happens after I submit
  After submission, the care team reviews the plan, adds it to the record, and uses it during follow-up visits or outreach if relapse risk increases.

Recovery Goals and Current Status

• Primary recovery goal
  Briefly describe the main goal for recovery or relapse prevention.
• Current stage of recovery
• Date of last relapse or use
  Optional. Only collect if relevant to the care plan.
• High-risk times or situations
  Select any times when relapse risk tends to be higher.

Triggers and Early Warning Signs

• Known triggers
  Select all that apply.
• Other trigger details
  Describe any triggers not listed above.
• Early warning signs
  Select signs that often appear before relapse risk increases.
• Personal warning signs
  Add any warning signs that are specific to this patient.

Coping Strategies and Protective Factors

• Coping strategies that help
• Describe the most effective coping strategies
  Include step-by-step details if a specific strategy works best.
• Protective factors
  Select supports that reduce relapse risk.
• Daily routine supports
  Describe routines that help maintain stability, such as sleep, meals, exercise, and appointments.

Support Resources and Escalation Plan

• Primary support person name
  Optional. Enter only if the patient wants a named support contact.
• Primary support person phone
  Optional. Enter only if the patient wants this contact used for support.
• Professional support resources
• Immediate steps if relapse risk becomes high
  Describe what the patient will do if cravings, urges, or risk escalate. Include emergency or crisis resources if appropriate.
• Crisis or emergency contact included
  Check if the plan includes a crisis line, emergency department, or other urgent support resource.

Follow-Up and Review

• Planned review date
  Optional follow-up date for reviewing the plan.
• Preferred review frequency
• Additional notes
  Add any other relevant information needed for care coordination.