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Office of Mental Health

Home and Community Based Services Waiver
and Safety Plan Contract

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These are the things that usually make me most upset:

This is what I do when I start feeling upset:

The best things for me to do to stop feeling upset are:

When I feel upset, the people I would like to talk to or be with are:

When I am upset, I wish people would:  

I agree that I will try my best to do the things that make me feel better, when I first notice that I am starting to feel upset.

Required Signatures
Child:   Date:  
Parent:   Date:  
ICC:   Date:  
Teacher (if school is involved:   Date:  

 Rev.5/10

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.