16 Brown Stanley Safety Plan (IOP Admit Packet)

Patient Safety Plan Template
Name*

First NameLast Name
Email*
example@example.com
Received by:
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

First NameLast Name
Phone Number

Area CodePhone Number
2. Name

First NameLast Name
Phone Number

Area CodePhone Number
3. Place
4. Place
Step 4: People whom I can ask for help:
1. Name

First NameLast Name
Phone Number

Area CodePhone Number
2. Name

First NameLast Name
Phone Number

Area CodePhone Number
3. Name

First NameLast Name
Phone Number

Area CodePhone Number
Step 5: Professionals or agencies I can contact during a crisis:
1. Clinician Name

First NameLast Name
Phone Number

Area CodePhone Number
Clinician Pager or Emergency Contact #
2. Clinician Name

First NameLast Name
Phone Number

Area CodePhone Number
Clinician Pager or Emergency Contact #
3. Local Urgent Care Services
Urgent Care Services Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
4. Urgent Care Services Phone

Area CodePhone Number
Suicide Prevention Lifeline Phone: 1-800-273-TALK (8255)
Step 6: Making the environment safe:
1.
2.
The one thing that is most important to me and worth living for is:
Signature*

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Patient Safety Plan Template