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Relapse Prevention Plan

Relapse Prevention Plan - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires




Relapse Prevention Plan
Date: ________________

Purpose: Depression can occur multiple times during a person’s lifetime. The purpose of a relapse prevention plan
is to help you understand your own personal warning signs. These warning signs are specific to each person and
can help you identify when depression may be starting to return so you can get help sooner – before the symptoms
get bad. The other purpose of a relapse prevention plan is to help remind you what has worked for you to feel
better. Both of these put YOU in charge!

Instructions: 1. Fill out this form with your care manager. 2. Put it where you’ll come across it on a regular basis.
3. Use the PHQ-9 on the back to self-assess yourself. 4. If you see signs of returning depression, use your
prevention plan.


Maintenance medications
1. _________________; ________tablet(s) of _______mg ______Take at least until_________________
2. _________________; ________tablet(s) of _______mg ______Take at least until_________________
3. _________________; ________tablet(s) of _______mg ______Take at least until_________________
4. _________________; ________tablet(s) of _______mg ______Take at least until_________________
Call your primary care provider or your care manager with any questions (see contact information below).

Other treatments
1. _______________________________________________________________________________________
2. _______________________________________________________________________________________
3. _______________________________________________________________________________________

Personal warning signs
1. _______________________________________________________________________________________
2. _______________________________________________________________________________________
3. _______________________________________________________________________________________
4. _______________________________________________________________________________________
Things that help me feel better
1. _______________________________________________________________________________________
2. _______________________________________________________________________________________
3. _______________________________________________________________________________________
4. _______________________________________________________________________________________
If symptoms return, contact: ____________________________________________________________


Primary Care Provider: ______________________ Phone: ___________________ Email: ______________
Care Manager: ______________________ Phone: ___________________ Email: ______________

Next appointment: Date: _______________ Time: __________________