Safety Planning Form

SAFETY PLAN

Step 1: Warning signs: (What sets this off? Events, substance use?)

  1. ___________________________________________________________________
  2. ___________________________________________________________________
  3. ___________________________________________________________________

Step 2: Internal coping strategies – Things I can do to distract myself without contacting anyone: (Ex. walking, listening to music, cleaning, etc.)

1.______________________________________________________________________

2.______________________________________________________________________

3.______________________________________________________________________

Step 3: Social situations and people that can help to distract me: (Ex. Grocery store, park, zoo, etc.)

  1. _______________________________________________________________
  2. _______________________________________________________________
  3. _______________________________________________________________

Step 4: People who I can ask for help:

  1. Name___________________________________ Phone __________________
  2. Name___________________________________ Phone___________________
  3. Name___________________________________ Phone __________________

Step 5: Professionals or agencies I can contact during a crisis:

  1. Clinician Name__________________________ Phone___________________

Emergency Contact #_________________________________________

  1. Clinician Name_________________________ Phone____________________

Emergency Contact #_________________________________________

  1. Local Hospital ED _____________________________________________________

Local Hospital ED Address________________________________________

Local Hospital ED Phone _________________________________________

  1. Suicide Prevention Lifeline Phone: 1-800-273-TALK
  2. The Trevor Project: 1-866-488-7386
  3. OREGON BEHAVIORAL HEALTH SUPPORT LINE 800-923-4357
  4. ALCOHOL & DRUG HELPLINE 800-923-4357
  5. SENIOR LONELINESS LINE Call 503-200-1633
  6. YOUTHLINE Call 877-968-8491

Making the environment safe:

  1. ________________________________________________________________
  2. ________________________________________________________________
  3. ________________________________________________________________