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about bipolar disorder
depressive disorders
Bipolar Disorder 1on1
Action Plan
Reminders:
 Discuss
this planwith your doctor |
|
|
Take Action |
||
| Name: __________________________________ | Date:_______ | |
| Filled out by: _____________________________ | ||
Take
it toSleep Pattern:
_____ Sleepless nights in _____ days
| | Take sleep aid as prescribed: ________________________ |
| | Call my doctor if:: _________________________________ |
| | Other: __________________________________________ |
Diet
| | Regular |
| | Low carbohydrate |
| | Low fat |
| | Other: __________________________________________ |
| INCLUDE: ______________________________________ | |
| AVOID: _________________________________________ |
Exercise Program:
| | I will exercise ______ minutes ______ times/week |
| | My exercise includes: ______________________________ |
Social Activities:
| | I will take part in: _____ social activities _____ times/week |
| | Social activities include: _____________________________ |
Other signs to watch for with my illness:
| ________________________________________________ | |
| ________________________________________________ | |
| ________________________________________________ |
Drug and Alcohol Use:
| | Discuss use of street drugs and alcohol with my doctor |
| | Call my therapist or counselor when I need support |
| | Other: __________________________________________ |
Counseling/ Support Groups:
| | Individual counseling: ______________________________ |
| | Family or group counseling:: ________________________ |
| | Support group: ___________________________________ |
| | Other: _________________________________________ |
Suicidal Thoughts:
Call 911 before acting on any suicidal thoughts.
| | Call my doctor or the crisis center hotline: ________________ |
| | Call emergency contact (family or friend): ________________ |
Important Telephone Numbers:
CALL 911 for a life-threatening emergency
|
Name |
Telephone Number |
|
Local crisis center or suicide hotline: |
|
| ____________________________ | _______________________ |
|
Emergency contact (family or friend): |
|
| ____________________________ | _______________________ |
| Psychiatrist: | |
| ____________________________ | _______________________ |
| Therapist or Counselor: | |
| ____________________________ | _______________________ |
| Primary care doctor: | |
| ____________________________ | _______________________ |
| Pharmacy | |
| ____________________________ | _______________________ |
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