Crisis/safety Plan

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Crisis / Safety Plan
When: (name and action/thought) __________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________is to:
1) __________________________________________________________________
2) _________________________________________________________________
3) _________________________________________________________________
4) _________________________________________________________________
5) _________________________________________________________________
___________________________is to:
1) _________________________________________________________________
2) _________________________________________________________________
3) _________________________________________________________________
4) _________________________________________________________________
5) _________________________________________________________________
If this does not work, follow the phone tree:
1) _________________________________________________________________
2) _________________________________________________________________
3)
_________________________________________________________________
I assisted with the creation of and agree with the contents of this plan:
Client:
X _____________________________________Date:__________
Parent/Guardian X _____________________________________Date:__________
Worker
X _____________________________________Date:__________

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