Crisis Plan/ Safety Plan
The purpose of a safety plan is to write down your plan to use when you need it to ensure you are safe and able to cope with the events.
Client Name
*
First Name
Last Name
Client Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1. Write 3 warning signs that a crisis may be developing. (State ways you know when you are not doing well such as sweaty palms, shaking, panic, crying, yelling, etc)
*
2. Write 3 internal coping strategies that can take your mind off your problems. (State things you do that help you cope with the crisis)
*
3. Who/What are 3 people or places that provide distraction? (What helps you take your mind off of the crisis?)
*
4. Who can you ask for help? (name and relationship)
*
5. Professionals or agencies you can contact during a crisis:
*
6. Write out a plan to make your environment safer. (What can you do to make yourself safe or calm when in a crisis or not doing well? Ex: walk outside, remove weapons, ask for support, separate from the situation)
*
Person completing form name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: