Safety Plan Template 1 - Free Download
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Safety Plan Template 1
Safety Plan Template 1
Sample Safety Plan
Step 1: Warning signs (thoughts, images, mood, situation, behavior) that a crisis may be
developing:
1. _____________________________________________________________________________________________
2. _____________________________________________________________________________________________
3. _____________________________________________________________________________________________
Step 2: Internal coping strategies – Things I can do to take my mind off my problems
without contacting another person (relaxation technique, physical activity):
1. _____________________________________________________________________________________________
2. _____________________________________________________________________________________________
3. _____________________________________________________________________________________________
Step 3: People and social settings that provide distraction:
1. Name____________________________________________________Phone______________________________
2. Name____________________________________________________Phone______________________________
3. Place__________________________________________4.Place______________________________________
Step 4: People whom I can ask for help:
1. Name____________________________________________________Phone______________________________
2. Name____________________________________________________Phone______________________________
3. Name____________________________________________________Phone______________________________
Step 5: Professionals or agencies I can contact during a crisis:
1. ClinicianName____________________________________________Phone______________________________
ClinicianPagerorEmergencyContact#_________________________________________________________
2. ClinicianName____________________________________________Phone______________________________
ClinicianPagerorEmergencyContact#_________________________________________________________
3. LocalUrgentCareServices______________________________________________________________________
UrgentCareServicesAddress___________________________________________________________________
UrgentCareServicesPhone_____________________________________________________________________
4. SuicidePreventionLifelinePhone:1-800-273-TALK(8255)
Step 6: Making the environment safe:
1. _____________________________________________________________________________________________
2. _____________________________________________________________________________________________
SafetyPlanTemplate©2008BarbaraStanleyandGregoryK.Brown,isreprintedwiththeexpresspermissionoftheauthors.NoportionoftheSafetyPlanTemplatemaybereproduced
withouttheirexpress,writtenpermission.Youcancontacttheauthorsatbhs2@columbia.eduorgregbrow@mail.med.upenn.edu.
Theonethingthatismostimportanttomeandworthlivingforis:
________________________________________________________________
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