Student Safety Plan

Student’s Name:  	

DOB: 	

Date: 	

Triggers		Warning Signs	
There are certain situations or circumstances which make me feel uncomfortable and/or agitated:		I should use my safety plan when I notice these warning signs (thoughts, images, moods, situations, behaviors):	
1.		1.	
2.		2.	
3.		3.	

Coping Skills/Healthy Behaviors		
Places I Feel Safe	
Things I can do to calm myself down or feel better in the moment (e.g. favorite activities, hobbies, relaxation techniques):		Places that make me feel better and make me feel safe (can be a physical location, an imaginary happy place, or refer in the presence of safe people):	
1.		1.	
2.		2.	
3.		3.	

School Support		
Adult Support	
Healthy adults at school and/or ways school staff can give me support:		Healthy adults at home or in my community, whom I trust and feel comfortable asking for help during a crisis (include phone number):	
1.		1.	
2.		2.	
3.		3.	

Parent Support		
Case Carrier Support	
Actions my parent/guardian can take to help me stay safe:		Actions my case carrier can take to help me stay safe:	
1.		1.	
2.		2.	
3.		3.	

Outside Mental Health Agency Providing Me Support	
Mental Health Agency:    			
Clinician Name:	 		Office #:   		
Clinician Email:	 		Cell #:   		

During a crisis, I can also call:

911 For Immediate Support
Los Angeles County Department of Mental Health ACCESS (800) 854-7771 – (24 hours)
Suicide Prevention Lines (24 Hours)
National Suicide Prevention Lifeline (800) 273-TALK or (800) 273-8255
Suicide Prevention Crisis Line	(877) 727-4747
National Hopeline Network	(800) SUICIDE or (800) 784-2433
California Youth Crisis Line (800) 843-5200 – 24 hours, bilingual
TEEN LINE (310) 855-HOPE or (800) TLC-TEEN – a teen-to-teen hotline with community outreach services, from 6pm-10pm PST daily. Text, email and message board also available, with limited hours-visit http://teenlineonline.org for more information.
The Trevor Project (866) 4-U-TREVOR or (866) 488-7386 – a 24 hour crisis line that provides crisis intervention and suicide prevention services to lesbian, gay, bisexual, transgender and questioning (LGBTQ) young people ages 13-24. Text and chat also available, with limited hours-visit www.thetrevorproject.org for more information.

Signatures

Student Signature	Date

Parent/Guardian Name (please print)	Phone#

Parent /Guardian Signature	Date

Administrator/Case Carrier (please print)	Title

Administrator/Case Carrier Signature	Date