Notification of Safety Plan (Template) I, _____________________________________, together with __________________________________ Student Name

School Counselor, Principal, or Designee

have developed this plan to help me keep safe. This safety plan will be/has been reviewed with ______________________________________, so that they can help me to follow the plan and support me to feel Parent/Guardian Name

better, cope safely, and stay alive. ____________________________________________________

_____________________________________________________

Student’s Signature

Parent/Guardian Signature

Date

Date

______________________________________ Signature of School Representative

Date

Part 1: I will be aware of these situations and behaviors that tend to upset me to a serious degree: 1. 2. 3.

4.

Part 2: I will pay attention to my warning signs (thoughts, feelings, body sensations) that I’m upset: 1. 2. 3.

4.

Part 3: When I notice my early warning signs I will try to calm myself down by doing the following: 1. 2. 3.

4.

Part 4: If I am unable to calm down on my own, I will ask for help from these safe and supportive adults: 1. 2. 3.

4.

Part 5: When I’m upset, my Parent/Guardian can help me by saying or doing these things: 1. 2. 3.

4.

5. Making the home environment safer by maintaining direct supervision of the youth; removing firearms, weapons, and poisons; and either removing or putting under secure, locked storage harmful substances such as alcohol, prescriptions and over the counter medications. Part 6: If I feel that neither I nor my Parent/Guardian can keep me safe, then our crisis plan is: 1. Call 9-1-1 for emergency services or go to nearest hospital ER, if safe to transport 2. Call the National Suicide Prevention Lifeline at 1-800-273-TALK or 1-800-273-8255 3. Call the Crisis Intervention Center Hotline, the Phone, at 1-800-437-0303. This form is based on the Safety Plan Template by Barbara Stanley and Gregory K. Brown @2008

Safety Plan Template.pdf

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