### Sample Safety Plan

**Patient Name**: John Doe  
**Date**: [Current Date]  
**Clinician**: Dr. Smith

#### **1. Warning Signs**
**Identify signs that indicate a crisis might be developing.**

- Persistent or worsening feelings of sadness, hopelessness, or worthlessness.
- Increased anxiety or panic attacks.
- Thoughts of self-harm or suicide.
- Withdrawal from social interactions and activities.
- Increased substance use or risky behaviors.
- Trouble sleeping or significant changes in sleep patterns.

#### **2. Coping Strategies**
**List personal coping strategies the patient can use to manage their symptoms.**

- Practice deep breathing exercises or mindfulness meditation.
- Engage in physical activities like walking, jogging, or yoga.
- Distract yourself with hobbies, such as reading, drawing, or gardening.
- Write in a journal to express feelings and thoughts.
- Listen to calming or favorite music.

#### **3. Social Supports**
**Identify people the patient can contact for support.**

- **Family Members**:
  - [Name, Relationship, Phone Number]
  - [Name, Relationship, Phone Number]

- **Friends**:
  - [Name, Relationship, Phone Number]
  - [Name, Relationship, Phone Number]

- **Support Groups**:
  - [Name of Group, Contact Person, Meeting Time/Location]

#### **4. Professional Resources**
**List mental health professionals and crisis resources the patient can contact.**

- **Primary Clinician**:
  - Dr. Smith, [Phone Number], [Email]

- **Therapist/Counselor**:
  - [Therapist's Name], [Phone Number], [Email]

- **Emergency Contact**:
  - [Emergency Contact Person, Phone Number]

- **Local Crisis Hotline**:
  - [Hotline Name, Phone Number]

- **National Suicide Prevention Lifeline**:
  - 1-800-273-TALK (8255) or text "HELLO" to 741741

#### **5. Safe Environment**
**Steps to make the environment safe and reduce access to means of self-harm.**

- Remove or secure potentially harmful objects (e.g., sharp objects, medications).
- Keep emergency contact numbers readily accessible.
- Develop a plan to stay with a trusted friend or family member during high-risk times.

#### **6. Emergency Steps**
**Specific steps to follow if the patient feels they are in immediate danger.**

1. **Recognize Warning Signs**: Acknowledge the signs of a crisis.
2. **Use Coping Strategies**: Implement personal coping strategies listed above.
3. **Reach Out for Support**: Contact a trusted friend, family member, or support group.
4. **Contact Professional Help**: Call the primary clinician, therapist, or crisis hotline.
5. **Seek Emergency Assistance**: If feeling unsafe or unable to manage the crisis:
   - Call 911 or go to the nearest emergency room.
   - Inform emergency services of the immediate risk of self-harm or suicide.

#### **7. Follow-Up Plan**
**Outline the follow-up plan to ensure continued support and monitoring.**

- **Next Appointment**: [Date and Time]
- **Check-In Calls**: Schedule regular check-in calls or messages from the clinician or support person.
- **Therapy Sessions**: Continue attending scheduled therapy sessions.
- **Medication Review**: Regularly review the effectiveness and side effects of medications.

**Patient Signature**: ______________________  **Date**: _______________

**Clinician Signature**: ____________________  **Date**: _______________

### Notes:
- Keep this safety plan in a place where it can be easily accessed during a crisis.
- Review and update the safety plan regularly, especially after any significant changes in symptoms or life circumstances.