Suicide Safety Plan
Develop Plan with Your Clinician and Save it in a Place for you and your close family
Date of Service
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Month
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Day
Year
Date of Visit
Patient Name
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First Name
Last Name
Your Clinician:
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Faisal Rafiq MD.
Yasmine Saim PA.-C
Joan Mahoney NP.
Step 1: Recognizing warning signs that signal that you need to find help:
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Identify specific thoughts, feelings, situations and behaviours that may predict a crisis. Examples include: feeling that emotional pain will never end, having persistent thoughts that others would be better off without you.
Step 2: What can you do by yourself to take your mind off the problem? What obstacles might there be to using these coping skills? List activities that may take your mind off your suicidal feelings. This allows time to pass and for the impulses to subside. Simple, engrossing activities can be surprisingly helpful.
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Examples include listening to calming music, exercising, going for a walk or playing a musical instrument.
Step 3: If you are unable to deal with your distressed mood alone, contact trusted family or friends, and think of social settings that offer support as well as distraction from the crisis. List several people in case your first choices are not available.
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Name and Phone #
List Places that provides distraction:
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Step 4: Contact local health professionals or emergency services if you continue to have suicidal thoughts or serious distress. Create a list of names, phone numbers and locations that can be contacted during a suicide emergency. A crisis is no time to begin searching for this type of information.
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Emergency Contacts
Step 5: Make sure that access to any deadly means of self-harm are minimized. For example, limiting the number of pills available at any one time and removing any potentially harmful implements considered in plans. It is a myth that if someone wants to die by suicide, they will, no matter what. In fact, limiting access to deadly means makes a real difference. The strongest of suicidal feelings typically last only a brief period. If it is more difficult to act during these periods, there is a good chance that the suicidal feelings will subside. List What is most important to You and worth living for:
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Step 6: How I can make my environment safe:
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Submit
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