16 Brown Stanley Safety Plan (IOP Admit Packet)

Patient Safety Plan Template
Name *

First Name Last 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 Name Last Name
Phone Number

Area Code Phone Number
2. Name

First Name Last Name
Phone Number

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

First Name Last Name
Phone Number

Area Code Phone Number
2. Name

First Name Last Name
Phone Number

Area Code Phone Number
3. Name

First Name Last Name
Phone Number

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

First Name Last Name
Phone Number

Area Code Phone Number
Clinician Pager or Emergency Contact #
2. Clinician Name

First Name Last Name
Phone Number

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

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
4. Urgent Care Services Phone

Area Code Phone 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