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Run: Relapse Prevention Plan

A relapse prevention plan form for documenting triggers, warning signs, coping strategies, support contacts, and next steps after submission. Use it to turn ...

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Consent and Submission Details

This plan was developed collaboratively with the patient (required)

Confirm that the patient participated in creating this plan.

Yes No N/A

Consent to document relapse prevention information (required)

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.

Yes No N/A

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 (required)

Briefly describe the main goal for recovery or relapse prevention.

Current stage of recovery (required)

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 (required)

Select all that apply.

Other trigger details

Describe any triggers not listed above.

Early warning signs (required)

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 (required)

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 (required)

Immediate steps if relapse risk becomes high (required)

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.

Yes No N/A

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.

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