Patient Safety Plan Template

If a patient with safety concerns is not going to be hospitalized, then it is especially important to develop a good safety plan. Consider using national resources such as the safety plan below adapted from The National Suicide Prevention Lifeline:

Step 1: What to watch for that that a crisis may be developing: (thoughts, images, mood, situation, behavior)
1.  	
2. 	
3.  	

Step 2: Coping strategies – What I can do by myself do to take my mind off my problems (relaxation technique, physical activity):
1.  	
2.  	
3.  	

Step 3: Places and community (friend, family, neighbor, a coffee shop, a movie theater, a store) that provide distraction:
Name 	Phone 	
Name 	Phone 	
Place_ 	
Place_ 	

Step 4: Who can I ask for help:
Name 	Phone_ 	
Name 	_Phone 	
Name 	Phone_ 	

Step 5: Providers and resources 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: How I can make my environment safe:
1. 	
2.  	

The one thing that is most important to me and worth living for is: