NO HARM AGREEMENT



NO HARM AGREEMENT

I, the undersigned, agree that I will not cause bodily injury or death to myself or another person, either intentionally or unintentionally.

If I begin to feel that my behavior may become out of control or threatening in any way, I agree to follow one of the procedures listed below:

Between 8:00 AM and 5:00 PM on weekdays, I will call my counselor at the Counseling Center (221-3620) or come to the Center (phone service only from 12:00 noon – 1:00 PM) at Room 240 Blow Hall and ask for emergency assistance; or

After 5:00 PM and on weekends, I will contact the Campus Police ( 221-4596) for referral to the On Call Counseling Center Counselor and ask for assistance; or

Call Williamsburg Community Hospital (259-6005); or

Call 911.

I agree to attend all of my scheduled appointments with the Counseling Center.

My next scheduled appointment is ________________________

Other instructions from my counselor that I will follow are:

__________________________________________ __________________

Client Signature Date

__________________________________________ __________________

Counselor Signature Date

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