SAFETY PLAN

Name: [Name]
Made on: [Date]
Made with: [Clinician name, credentials, service]
Next review: [Date or appointment]
How I use it: When I notice my warning signs, I start at the top and work down. If one step doesn't help, I go to the next. If I might act on my thoughts, I call 988 or 911 right away.

MY REASONS FOR LIVING
[People, pets, plans, beliefs, or hopes, in my own words]

MY EARLY WARNING SIGNS
What I think: [Thoughts or phrases that show up]
What I feel: [Changes in my mood and body]
What sets it off: [Places, times, dates, or events]
What I do: [Changes others might notice, such as pulling away or not sleeping]

WHAT HELPS WHEN I'M ON MY OWN
[Two to four things I can do by myself to get through the next hour]
[What I'll stop or avoid, such as alcohol or searching online]

PLACES AND PEOPLE TO BE AROUND
Places: [Where I can go to be around other people]
People: [Who I can spend time with without having to explain, and how to reach them]

PEOPLE I CAN TELL
[Name, phone number, and when they can be reached]
[Name, phone number, and when they can be reached]
What I'll say: [The words I'll use to ask for help]

CARE TEAM AND CRISIS LINES
My clinician: [Name, phone number, hours]
After hours: [The on-call or local crisis number]
Crisis line: 988, call or text, any time
Emergency: 911, or go to [Nearest emergency department and its address]
Next appointment: [Date, time, and how to change it]

WHAT I'M PUTTING OUT OF REACH
Firearms: [Stored outside the home and with whom, locked with the key held by someone else, or none in the home]
Medications: [What is removed, locked away, or kept in small amounts, and who holds them]
Other means: [Anything else I've thought about using, and the step agreed]
Who is helping: [Who has agreed to help, and by when]

FOR THE CLINICAL RECORD
How it was made: [Written together, in the person's words, after the risk assessment on date]
Likelihood of use: [How likely the person says they are to use it, and the barriers discussed]
Copies: [Who has a copy, with consent, and where the person keeps theirs]
Means confirmed: [What was confirmed, by whom, how, and when]
Follow-up: [Next contact or appointment, with date]
Review: [Each session while risk continues, after any crisis, and at each move between services]

Signed: [Clinician name, credentials, date and time]