Patients' Safety and Emergency Plan

Welcome to Our Patients' Safety and Emergency Plan - SI Page!

Your safety is our top priority. Our Patients' Safety and Emergency Plan - SI is designed to ensure the highest standards of care and preparedness. Here, you'll find comprehensive guidelines and procedures aimed at protecting you in various emergency scenarios.

Thank you for trusting us with your well-being.

Patients' Safety and Emergency Plan - SI

Patient First Name

Patient Last Name

Birthday

Today's Date

Phone

Step 1: Warning Signs Recognizing When I’m in Crisis

Thoughts:

Feelings:

Behaviors

Step 2: Internal Coping Strategies Things I Can Do to Distract Myself and Feel Better Without Contacting Others:

Step 3: Social Contacts and Safe Places People and Places That Provide Distraction People I Can Contact:

Name

Phone

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Name

Phone

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Name

Phone

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Safe Places I Can Go:

Step 4: Family and Friends Who Can Help People Who Can Help Me in a Crisis

Name

Phone

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Name

Phone

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Name

Phone

Step 5: Professional and Agency Contacts Professionals or Agencies to Contact During a Crisis

Therapist:

Name

Phone

Psychiatrist/Provider:

Name

Phone

Crisis Hotline: Suicide Prevention Lifeline Phone: 1-800-273-TALK (8255) Emergency Service Contact: 911 Local Urgent Care Services

Name

Address

Step 6: Making the Environment Safe Steps I Can Take to Make My Environment Safe. Remove or secure any means of self-harm (e.g., pills, sharp objects)

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Medications (Store them in a secure place)

Step 7: My Reasons for Living Things Worth Living For

Step 8: Reviewing the Plan How Often and With Whom Will I Review This Plan?

Frequency to review

Person to review with

Emergency Protocol If I Cannot Stay Safe:

Call 911 or Go to the Nearest Emergency Room Immediately:

Contact My Emergency Contact:

Name

Phone

Short answer

PATIENT'S SIGNATURE

CLINICIAN'S SIGNATURE

Instructions for Use Keep this plan in an easily accessible place. Review and update the plan regularly, especially after any crisis or change in circumstances. Share the plan with trusted family members, friends, and healthcare providers.

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