Patient Safety Plan

This safety plan is a collaborative document completed with the client to help manage suicidal urges or crisis situations.

Current Risk Assessment

1. Ideation Level

0 — None 1 — Wish Dead 2 — Nonspecific Thoughts 3 — With Method 4 — With Intent 5 — With Plan

1. Actual Attempt

Self-Injurious Behavior with Intent to Die

2. Interrupted Attempt

3. Aborted/Self-Interrupted Attempt

4. Preparatory Acts or Behaviors

5. Non-Suicidal Self-Injury (NSSI)

Most Recent Behavior

yyyy-mm-dd

Lethality (0-10)

Clinician Risk Override

No Override

Step 1 — Triggers & Stressors

Interpersonal conflict

Rejection / Loss

Substance use

Isolation / Loneliness

Anniversary / Reminder of trauma

Financial stress

Health crisis

Other triggers:

Step 2 — Warning Signs

Thoughts of death / ending life

Hopelessness / Feeling trapped

Rage / Uncontrolled anger

Increased anxiety / Panic

Sleep disruption

Social withdrawal

Increased substance use

Giving away possessions

Other warning signs:

Step 3 — Internal Coping Strategies

Deep breathing / Grounding

Exercise / Movement

Music / Art

Journaling / Writing

Mindfulness / Meditation

Go to a safe place

Prayer / Spiritual practice

Cold water / Ice / Shower

Other coping strategies:

Step 4 — Distracting People & Social Settings

Person / Social Setting	Contact / Location

Step 5 — Supportive Contacts for Help

Supportive Friend / Family Member	Phone / Contact

Step 6 — Professionals & Emergency Agencies

Professional / Agency	Phone	Details
Primary Clinician
988 Suicide & Crisis Lifeline	988	24/7 — call or text
Crisis Text Line	Text HOME to 741741	24/7 text support
Local Emergency / ER	911	Go to nearest ER

Step 7 — Environmental Safety

Firearms removed / secured

Medications secured

Sharps secured

Other means addressed

Additional safety steps:

Most Important Reason for Living:

Documentation

Safety plan reviewed with client

Copy given to client

Copy in chart

Follow-up:

Plan and Follow-Up

Plan area	Details
Next visit	When the patient should return and the reason for that interval. Interval:
Orders & referrals	Labs, imaging, or referrals placed at this visit. Orders / referrals:
Patient instructions	Home care, medication or supplement changes, and education provided. Instructions:
Monitoring & safety	What to monitor and when to escalate or seek urgent care. Monitor / escalate:

Counseling - Patient Safety Plan

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