Safety Plan
Client Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Client Email
*
example@example.com
Clinician/Therapist
*
Please Select
Abigail Bensko
Alexis Olson
Alyssa Hodge
Andreea Felea
Annalise Saylor
Arias Gonzales
Ashley Munger
Barbra Styles
Bonna Machlan
Chelsea Bruntmyer
Courtney Fisher
Cristyn Smith
Crystal Robertson
David Geldert
Deb Corbitt
Donna Janiec
Dusty Bransford
Edmund Miranda
Elizabeth Klearry
Emily Kreiger
Erin Henrich
Gabriel Cruz Rosa
Geni Hunt
Grace Combs
Heather Comensky
Jackie Erwin
Jemima Organ
Jenifer Seas
Jennifer Luttman
Jennifer Wilson
Jessica Titone
Joshua Goldberg
Julesy Flavelle
Karin Alaska
Kate Prensner
Katelynn Dwyer
Katherine Miller
Kelly Bergstedt
Kelsey Morrow-Wright
Kelsey Maestas
Kristen Yamaoka-Los
Laura Hunt
Lauren Day
Liliana Ismail
Lindsey Gallop
Lori Geissinger
Mallory Heise
Margot Bean
Maria Roncalli
Marlys Hersey
Marta Schmuki
Megan Brausam
Melanie Warning
Melissa Johnston
Naomi Kettner
Noah Suess
Paitton Callery
Rachel Hazelwonder
Sara Deen
Sarah Lawler
Shannon Matlock
Shannon Hamm
Shawna Fishman
Stephanie Kol
Support Team
Tawny George
Tiara Lindsley
Tracey Lundy
Therapists Email
Trauma Experienced
*
Rows
Plan
1
2
3
4
5
6
Triggers (specific situations) that could lead to a crisis:
*
Rows
Plan
1
2
3
4
5
6
My early warning signs (that a safety crisis is developing) are:
*
Rows
Plan
1
2
3
4
5
When my parents/caregivers notice my early warning signs, they can:
*
Rows
Plan
1
2
3
4
Ways I can cope or distract myself:
*
Rows
Plan
1
2
3
4
5
People or social settings to distract me:
*
Rows
Plan
1
2
3
If I am unable to help myself I can call:
*
Crisis text line HOME to 741741
Talk to parents let them know
Your County Crisis Line Phone Number: 844-493-8255 (TALK)
The National Suicide Hotline: 1-800-784-2433 or visit: https://suicidepreventionlifeline.org
One thing that is most important to me and worth living for:
*
Signature of Client
*
Submit
Should be Empty: