Contract for Survival

To cover the period of ________________to ________________.


I/We _______________________________________ agree not to knowingly or intentionally cause serious or fatal bodily harm or injury, including those actions which could result therein (i.e. overdose, reckless driving, etc.) to this physical, mental, emotional or spiritual body.

I/We will not knowingly kill, physically, mentally, emotionally or spiritually, ourselves or any other person or personality.

As protectors, we the undersigned, to the best of our ability, agree to intervene on behalf of our other persons or personalities who may be unable or unwilling to do so, by calling and actually reaching and connecting with the support members listed on this form.

When I call a support person, I will state that I am calling because of the contract and we will honestly address and discuss the emotions and events that led to crisis and the possible solutions and safety measures to be taken. We will continue to pursue all phone numbers, including repetitions, until the crisis is resolved.

In the event of breaking or attempting to break this contract, professional intervention may be contacted and requested.

Anyone who has reservations about signing this contract must voice them now or you are bound by this contract for the duration of the contract period.

This contract is valid past the end date until a new contract has been negotiated or all support members of the previously agreed upon contract have been contacted and agree that relinquishment of this contract is in the best interests of the contractee.


Signature of Host Personality


Signatures of those who agree to intervene on behalf of the host and others in the system:






I object to the signing of this contract. I will discuss my reasons here:






These are the persons/agencies I agree to call: Name and Phone Number






I, the undersigned support person(s) agree to provide emotional or physical support to the contractee within the terms of this contract. I understand the contractee may contact me any time of the day or night.




Hocking, Sandra al “Living with Your Selves” Launch Press .. reprinted with permission from Launch Press.


Oksana, Chrystine. Safe Passage to Healing – A Guide for Surivors of Ritual Abuse. New York: HarperCollins Publishers, 1994.