Patient Safety Plan Template

Step 1: Warning signs (thoughts, images, mood, situation, behavior) that a crisis may be

developing:

1. _____________________________________________________________________________________________

2. _____________________________________________________________________________________________

3. _____________________________________________________________________________________________

Step 2: Internal coping strategies – Things I can do to take my mind off my problems

without contacting another person (relaxation technique, physical activity):

1. _____________________________________________________________________________________________

Step 4: People whom 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______________________________

Clinician Pager or Emergency Contact # _________________________________________________________

2. Clinician Name____________________________________________ Phone______________________________

Clinician Pager or Emergency Contact # _________________________________________________________

3. Local Urgent Care Services______________________________________________________________________

_____________________________________________________________________________________________

The one thing that is most important to me and worth living for is:

________________________________________________________________