Relapse Prevention / Sobriety Maintenance Plan Template

[Full Name]

[Date of Birth: MM/DD/YYYY]

[Street Address]

[City, State/Province, ZIP/Postal Code]

[Phone Number]

[Email Address]

Date Completed: [MM/DD/YYYY]

Plan Review Date: [MM/DD/YYYY]

1. Recovery Summary

Primary Substance(s) of Concern: [Substance(s)]

Sobriety Date (or most recent clean date): [MM/DD/YYYY]

Current Recovery Supports (check or describe):

• [AA / NA / 12-step meetings]

• [Outpatient or inpatient treatment]

• [Individual counseling or therapy]

• [Medication-assisted treatment]

• [Faith-based or community support]

• [Other: [Description]]

DUI-Related Case (if applicable):

Case / Docket Number: [Number]

Court / Program Name: [Name]

2. Personal Reasons for Sobriety

My main reasons for staying sober are:

• [Reason 1, e.g., “My health and safety.”]

• [Reason 2, e.g., “My children and family.”]

• [Reason 3, e.g., “Keeping my job and license.”]

• [Reason 4, e.g., “Avoiding further legal trouble.”]

Long-Term Goals Related to Sobriety:

• [Goal 1]

• [Goal 2]

• [Goal 3]

3. Triggers and High-Risk Situations

Common people, places, things, or situations that can trigger cravings or thoughts of using:

People:

• [Example: Certain friends, coworkers, or family members]

Places:

• [Example: Bars, clubs, neighborhoods, houses, or events]

Situations and Events:

• [Example: Parties, holidays, concerts, paydays, being alone, late nights]

Thoughts and Feelings:

• [Example: Stress, anger, boredom, loneliness, shame, depression, anxiety]

4. Early Warning Signs of Relapse

Physical, emotional, and behavioral warning signs that may show I am moving toward relapse include:

Physical Signs:

• [Example: Trouble sleeping, headaches, stomach problems, low energy]

Emotional Signs:

• [Example: Irritability, mood swings, hopelessness, feeling numb]

Behavioral Signs:

• [Example: Skipping meetings or appointments, isolating, lying, contacting old using friends, driving by old places, thinking “one drink won’t hurt”]

5. Coping Strategies and Healthy Alternatives

Healthy ways I can cope with cravings, stress, and difficult emotions instead of using alcohol or drugs:

Immediate Coping Tools (for cravings or urgent situations):

• [Tool 1, e.g., “Call a sponsor or trusted friend.”]

• [Tool 2, e.g., “Use grounding or breathing exercises.”]

• [Tool 3, e.g., “Go to a meeting or online group.”]

• [Tool 4, e.g., “Leave the high-risk situation immediately.”]

Ongoing Healthy Habits:

• [Habit 1, e.g., “Regular exercise or walking.”]

• [Habit 2, e.g., “Journaling, meditation, or prayer.”]

• [Habit 3, e.g., “Spending time with supportive family or friends.”]

• [Habit 4, e.g., “Hobbies, creative activities, or volunteering.”]

6. Daily and Weekly Sobriety Routine

Daily Routine to Support Sobriety:

• Morning: [Examples: Reading recovery literature, planning the day, brief check-in call or message, gratitude list]

• Daytime: [Examples: Work or school, scheduled breaks, healthy meals, short walk]

• Evening: [Examples: Meeting attendance, family time, self-care, reflection on the day]

Weekly or Regular Recovery Activities:

• Meetings (AA/NA/other): [Number] times per week at [Locations / Groups]

• Counseling / Therapy Sessions: [Frequency and provider]

• Check-ins with Sponsor / Mentor: [Frequency]

• Other Support Activities: [Description]

7. Support Network and Contact Information

People I can contact when I need help, feel cravings, or notice warning signs:

Primary Support Person:

Name: [Name]

Relationship: [Relationship]

Phone: [Phone Number]

Sponsor / Mentor (if applicable):

Name: [Name]

Program / Group: [AA/NA/Other]

Phone: [Phone Number]

Additional Support Contacts:

1. Name: [Name] – Relationship: [Relationship] – Phone: [Phone Number]

2. Name: [Name] – Relationship: [Relationship] – Phone: [Phone Number]

3. Name: [Name] – Relationship: [Relationship] – Phone: [Phone Number]

8. Emergency / Crisis Plan

If I feel close to using, am in a high-risk situation, or have already slipped and used, I will:

Step 1 – Immediate Safety:

• [Example: Leave any unsafe place, stop driving, and go to a safe location.]

Step 2 – Contact Support:

• [Example: Call or text my sponsor, therapist, or trusted friend.]

Step 3 – Use Emergency Coping Skills:

• [Example: Breathing exercises, grounding techniques, cold water on hands/face, short walk.]

Step 4 – Recovery Action:

• [Example: Attend the next available meeting in person or online, or contact my treatment program.]

Step 5 – Follow-Up:

• [Example: Talk honestly with my sponsor/therapist about what happened and update this plan if needed.]

9. Driving and Legal Safety (If DUI-Related)

To prevent any future impaired driving or legal trouble, I commit to:

• Never driving after consuming alcohol or any impairing substance.

• Using taxis, rideshare, public transportation, or designated drivers when needed.

• Following all license restrictions, ignition interlock rules, and court or probation conditions.

• Discussing transportation plans with my support team when I know I will be in higher-risk situations.

10. Personal Commitments and Affirmation

My personal promises to myself and others about my sobriety and behavior:

• [Commitment 1, e.g., “I will ask for help when I am struggling instead of hiding it.”]

• [Commitment 2, e.g., “I will keep my appointments and meetings, even when I don’t feel like going.”]

• [Commitment 3, e.g., “I will be honest with my support network about slips or close calls.”]

Personal Sobriety Statement:

“I, [Full Name], commit to following this Relapse Prevention / Sobriety Maintenance Plan to the best of my ability. I understand that setbacks can happen, but I will use this plan and my support network to return to recovery as quickly as possible and to protect myself, my family, and the community.”

11. Signatures

Participant Signature: ___________________________

Printed Name: [Full Name]

Date: [MM/DD/YYYY]

[Optional] Therapist / Counselor / Sponsor Acknowledgment:

I have reviewed this Relapse Prevention / Sobriety Maintenance Plan with [Participant Name].

Signature: ___________________________

Name and Title/Role: [Name, Credentials or Role]

Date: [MM/DD/YYYY]