Safety Plan

Patient Safety Plan

Please fill out to the best of your ability.

Name*

Email Address*

Date*

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

Step 2:List THREE solutions to Internal coping strategies – Things you can do to take your mind off your problems without contacting another person (relaxation technique, physical activity): *

Step 3: List TWO people with contact information and TWO social settings that provide a safe place: *

Step 4: Name THREE people with contact information whom you can ask for help: *

Step 5: List TWO Clinicians with contact info and ONE Urgent Care you can contact during a crisis: *

Step 6: List TWO things that would make your environment safe: *

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

Suicide Prevention Lifeline Phone: 1-800-273-TALK (8255).

Georgia Crisis & Access Line (GCAL) at 1-800-715-4225, available 24/7.

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