I,_____________________________________, hereby agree that I will not harm myself in any way, attempt suicide, or die by suicide.

Furthermore, I agree that I will take the following actions if I am ever suicidal:

1) I will remind myself that I can never, under any circumstances, harm myself in any way, attempt suicide, or die by suicide.

2) I will call the local emergency number if I believe that I am in immediate danger of harming myself.

3) I will call any or all of the following numbers if I am am not in immediate danger of harming myself but have suicidal thoughts (please list names, phone numbers, addresses, and any other relevant contact information below):

4) I will continue talking on the phone with as many people as necessary for as long as necessary until the suicidal thoughts have subsided.

Signature______________________________    Date___________________

Witness_______________________________    Date___________________