Patient Safety Plan Template	

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:	
Name 	Phone 	
Name 	Phone 	
Place 	4. Place 		
Step 4:	People whom I can ask for help:	
Name 	Phone 	
Name 	Phone 	
Name 	Phone 		
Step 5:	Professionals or agencies I can contact during a crisis:	
Clinician Name 	Phone	 Clinician Pager or Emergency Contact #  		
Clinician Name 	Phone	 Clinician Pager or Emergency Contact #  		
Local Urgent Care Services 	                                                                                                          Urgent Care Services Address 	                                                                                                    Urgent Care Services Phone 	 
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: