Safety Planning

 

Safety Planning Form

SAFETY PLAN

 

Step 1: Warning signs:

  1. ___________________________________________________________________
  2. ___________________________________________________________________
  3. ___________________________________________________________________

 

Step 2: Internal coping strategies – Things I can do to distract myself without contacting anyone:

1.______________________________________________________________________

2.______________________________________________________________________

3.______________________________________________________________________

 

Step 3: Social situations and people that can help to distract me:

  1. _______________________________________________________________
  2. _______________________________________________________________
  3. _______________________________________________________________

 

Step 4: People who I can ask for help:

  1. Name___________________________________ Phone __________________
  2. Name___________________________________ Phone__________________

 

Step 5: Professionals or agencies I can contact during a crisis:

  1. Clinician Name__________________________ Phone___________________

Emergency Contact #___________________________________________

  1. Clinician Name_________________________ Phone____________________

Emergency Contact #___________________________________

 

  1. Local Hospital ED __________________________________________________

Local Hospital ED Address________________________________________

Local Hospital ED Phone _________________________

 

  1. Suicide Prevention Lifeline Phone: 1-800-273-TALK

 

Making the environment safe:

  1. ________________________________________________________________
  2. _________________________________________________________________
  3. ________________________________________________________________