Safety Plan

Therapist: Please complete the safety plan below and hit submit when done. upon completion of the session, please text the administrator to advise a safety plan was submitted. this safety plan will then be emailed to both the therapist and the client. thank you.

Today's Date

YYYY

Name of Therapist completing safety plan:

Name of Client

First Name

Last Name

Client's E-mail Address

Client's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client's Phone Number

(###)

###

####

Warning signs of a crisis:

Activities I can do by myself to help me take my mind off of things:

Please name three.

People I can go to:

Please include name and phone number for three people.

People I can call:

Please include name and phone number for three people.

Ways that supportive people can help me stay safe:

Important phone numbers I can call for help:

Please list local hospitals and law enforcement.

A few strengths that will help you manage:

Time of Completion

Hour

Minute

Second

Safety Plan

Soco Rey Therapy. Therapy that’s chill AF. Inglewood, CA