3.5 KiB
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.
- Recognize Warning Signs: Acknowledge the signs of a crisis.
- Use Coping Strategies: Implement personal coping strategies listed above.
- Reach Out for Support: Contact a trusted friend, family member, or support group.
- Contact Professional Help: Call the primary clinician, therapist, or crisis hotline.
- 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.