Safety Plan - DOC

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					                                                   Safety Plan
The following steps represent my plan for preparing in advance for the possibility of violence and increasing
my safety. Check boxes below that apply and complete descriptions to clarify action steps.

Home & Neighbor Safety
        I will meet with SSP staff and my neighbor for a conflict mediation meeting.

        I will report illegal/unsafe activity in my building to PPL property management.

        I will meet with PPL property management to discuss building safety (if applicable).

        I will avoid contact with my neighbor until we are all calm.

        I will talk with my neighbor 1:1 about my concerns using:
       o Translator services
       o Calm voice
       o Active listening without interruption
       o Respect for the other person and their perspective
       o “I feel…”/non-blaming language
       o No profanity and/or threatening language
       o Positive suggestions and problem solving

        I can call 911 if I don’t feel safe.

        I will review physical safety in my home. A safe place in my home is ___________________.

        I will tell my ________________ (counselor, advocate, etc.) about someone who is hurting me and
   seek the support I need to stay safe.

       I will inform the following people of someone abusing me and that they should call the police if the
   abuser is observed near my residence/if they hear suspicious noises coming from my house.
          a.       Neighbor __________________
          b.       Friend ____________________
          c.       Other ____________________

        I will meet with property management to have my partner removed from the lease (if applicable).

        I will call PPL property management to change my locks, if needed.

        If I have to leave my home, I can go to ________________________. If I cannot go there, I will go to
       ______________________.
                                                  Safety Plan
The following steps represent my plan for preparing in advance for the possibility of violence and increasing
my safety. Check boxes below that apply and complete descriptions to clarify action steps.



In case I have to leave, I will have the following available in one safe place:
             o important papers such as Driver’s license or ID, birth certificate, social security cards, insurance
                 information, school and health records, welfare and immigration documents, and divorce or other court
                 documents
             o credit cards, back account number and ATM cards, and some money
             o extra set of keys
             o medication and prescriptions
             o phone numbers and addresses for family, friends, doctor, lawyers and community agencies
             o clothing and comfort items for you (and your children)

      Other things I can do to stay safe are:
       ___________________________________________________________________________________________
       ___________________________________________________________________________________________
                                                     Safety Plan
The following steps represent my plan for preparing in advance for the possibility of violence and increasing
my safety. Check boxes below that apply and complete descriptions to clarify action steps.

Family & Children Safety
         I will let those who care for my children know of any safety concerns, and I will make clear who has permission
        to do so. I will inform:
                  1. School_____________________________________
                  2. Day Care___________________________________
                  3. Babysitter__________________________________
                  4. Teacher____________________________________
                  5. Others_____________________________________

           _______________ is my code word to let my children and friends know to call for help.

         I will teach my children to call _________________ (friend/other) in the event that I am absent or unable to
        care for them (due to illness/hospitalization).

           A list of my/ my child’s medications and doctors is stored___________________________________.

           In case of emergency I will meet my children in a safe place:
              o        Fire____________________________________
              o        Severe weather___________________________
              o        Tornado_________________________________

           If my child arrives home and I am not there, they should contact: __________________________
               o       If I have not returned in _____ hours they should contact:_________________________
               o       If I have not returned by the end of the day they should contact:____________________

         I understand that these standards of supervision must be met for my child. Child protection may need to be
        called in the following circumstance:
            Children under age 8 alone for any period of time.
            Children alone over 24 hours if parent whereabouts are unknown to children.
            Children 11 to 14 may baby-sit with the expectation that an adult will return later in day.
            Children 15 and older may baby-sit for more than 24 hours.
            In all of above, Child Protection Services will involve police for immediate safety check of children where
             appropriate.

Note: Children ages 8, 9, and 10 can be left alone during traditional working hours under certain circumstances. (before
and after school)
                                                  Safety Plan
The following steps represent my plan for preparing in advance for the possibility of violence and increasing
my safety. Check boxes below that apply and complete descriptions to clarify action steps.

        I will teach my children who it is okay to open the building/apartment door for and who it is not okay to open
       the building/apartment door for.

        I will teach my children what to say and not say when answer the telephone.

        I will teach my children who they are allowed to go with in the event someone claims they were instructed to
       pick them up; i.e. a stranger saying they were told to pick the children up.

        I will teach my children to call to me and _________________ (friend/other) in the event someone
       unsafe takes the children.

        When I am frustrated with my children, I will move to a safer room such as ____________________.

        If I need a break from my children or if my children need a safe place out of the home, ______________ is
       available to provide short-term (30min-2hour) care. ____________________ is available to provide overnight
       care. I can also use the Crisis Nursery – 763-591-0100.

        What age-appropriate information do I want to teach my child/children? (Examples: 911, phone numbers to
       call, neighbors to go to, how to talk to my child/children about violence).
       ___________________________________________________________________________________________
       ___________________________________________________________________________________________

        A list of my/ my child’s medications and doctors is stored___________________________________.

        My/my child’s medical condition, such as seizure/ asthma, protocols are stored________________________.
                                                  Safety Plan
The following steps represent my plan for preparing in advance for the possibility of violence and increasing
my safety. Check boxes below that apply and complete descriptions to clarify action steps.

Health & Wellness
      If I feel depressed or anxious, steps I can take are _______________________________.

      I can call the following people and/ or places for support:
       ___________________________________________________________________________________.

      Things I can do to make me feel stronger are:
       ___________________________________________________________________________________.

        If I have a medical emergency my children should call 911.

        Initial signs that I am having a medical emergency are:
       ___________________________________________________________________________________________
       _____________________________________________________________________________.

        Steps that should be taken at home to care for me before medical services arrive are:
       ___________________________________________________________________________________________
       _____________________________________________________________________________.

        A list of my/ my child’s medications and doctors is stored___________________________________.

        My/my child’s medical condition, such as seizure/ asthma, protocols are stored________________________.

        If I need to be hospitalized __________________ has permission to care for my children/pets.

        I have a living will or DNR (Do Not Resuscitate)/DNI (Do Not Intubate) plan in place.

        My allergies are:
       ___________________________________________________________________________________________
       _____________________________________________________________________________.

    If I am thinking about returning to a potentially unsafe situation, I can take the following steps:
       _________________________________________________________________________________.

    I can tell myself "___________________________________________" when I feel people are trying to
       control or abuse me.
                                                       Safety Plan
The following steps represent my plan for preparing in advance for the possibility of violence and increasing
my safety. Check boxes below that apply and complete descriptions to clarify action steps.

Drug and Alcohol Use

      In the event PPL has concerns regarding my chemical health they should contact: ________________________,
       _________________________ to pick up and provide care for my children in my absence or inability to care for
       my children.

      If I am having strong cravings to use, I will . . .

           o    Increase my 12 step meetings (Locations/ time of meetings):
                __________________________________________________________________________________
           o    Utilize therapy (Name and phone number of therapist):
                __________________________________________________________________________________
           o    Contact my sponsor (Name and phone number):
                __________________________________________________________________________________
           o    Inform my case manager/Family advocate:
                __________________________________________________________________________________

           o    Go to safe people who understand and who are committed to my safety: (Names and phone numbers)
                __________________________________________________________________________________
                __________________________________________________________________________________

           o    Go to safe places where you can think and experience a clear mind: (List places)
                __________________________________________________________________________________
                __________________________________________________________________________________

           o    I can also _________________________________________________________________________
                __________________________________________________________________________________

      If my partner is using, I can___________________________________________________________________

           o    I can also
                __________________________________________________________________________________
                __________________________________________________________________________________

      To protect my children, I can
       _______________________________________________________________________

      I can honor my commitment to sobriety and abstain from use.
                                               Safety Plan
The following steps represent my plan for preparing in advance for the possibility of violence and increasing
my safety. Check boxes below that apply and complete descriptions to clarify action steps.


Custody & Shared Responsibilities:

        I will set up a reasonable set schedule/ pick up and drop off for visitation with the non-custodial
       parent.

        The children will spend time with non-custodial parent every __________. And the _____ and
       _________ weekends of each month from ________. On Friday to _______ on Sunday.


        Exchange of all child(ren) from Mother to Father shall occur at:____________________


       Transportation arrangements for all child(ren) for all scheduled parenting times, including weekdays,
       weekends, holidays, and vacation times, shall be as follows:_______________________________


        Each parent shall always keep the other parent informed of his or her actual home and work
       telephone numbers and any changes within __________ hours of such change occurring.

       Neither parent shall say or do anything in the presence or hearing of the child(ren) that would in any
       way diminish the child(ren)’s love or affection for the other parent and shall not allow others to do so.

        All court related and financial communications between the parents shall occur at a time when the
       child(ren) are not present and, therefore, shall not occur at times of exchanges of the child(ren) or
       during telephone visits with the child(ren).

        Neither parent shall schedule activities for the child(ren) during the other parent’s scheduled
       parenting time without the other parent’s prior agreement, with the following
       exceptions:_________________________

        Parents shall attempt to resolve any matters on which they disagree or which involve interpreting
       the parenting plan through the following alternative dispute resolution process prior to any court
       action: Mediation by _______________________________________________

    I will seek out counsel in the event that I at any time feel that my children are not being treated
       properly by non-custodial parent.
                                                   Safety Plan
The following steps represent my plan for preparing in advance for the possibility of violence and increasing
my safety. Check boxes below that apply and complete descriptions to clarify action steps.


Order for Protections
         I will obtain an order for protection and can ask ________________ if I need assistance.

         I will call the domestic violence hotline if I am not sure how to register for a protection order.

         If I have a protection order, I can keep a copy ____________________ (location) and will call in any
        violations. I will also check with the police and county sheriff’s departments where I live to confirm my
        order is on file. The numbers are _____________ (police) and ________________ (sheriff).

         I can call PPL property management to change my locks, as well as request for a building trespass
        after I have a protection order in place.

         I will inform my advocate _________________ and employer _____________________ that I have a
        protection order in effect.

         If my partner violates the protection order, I will call the police and report it. I will call my
        advocate/counselor and/or tell the courts about the violation.

         If my protection order gets destroyed, I can go to the County Courthouse and get another copy.

         If I have to communicate with my abuser, the safest way for me to do so is __________________.

         If I feel threatened I can go into a store, gas station, restaurant to call __________________ for help.



I can review my safety plan periodically. By creating one, I have taken a proactive step, and I will continue to be
conscious of my own safety (and that of my children).


Participant signature ___________________________                Staff Signature _____________________________
                                                                      Safety Plan
The following steps represent my plan for preparing in advance for the possibility of violence and increasing
my safety. Check boxes below that apply and complete descriptions to clarify action steps.


                                                     Other Important Information
Emergency: 911
MN Poison Control Hotline: 1-800-222-1222
Crisis Nursery: 763-591-0100
Child Protection: call 911 or call your county: Hennepin (612) 348-3552; Ramsey (651) 266-4500

Doctor _____________________________                                         Phone number ____________________________
Doctor _____________________________                                         Phone number ____________________________
Employer ___________________________                                         Phone number ____________________________
School _____________________________                                         Phone number ____________________________
School _____________________________                                         Phone number ____________________________
School _____________________________                                         Phone number ____________________________
Friend/other _______________________                                         Phone number ____________________________
Friend/other _______________________                                         Phone number ____________________________
Neighbor __________________________                                          Phone number ____________________________
Case Manager _______________________                                         Phone number ____________________________
Day Care ____________________________                                        Phone number ____________________________


Medical Diagnosis/Allergies:
__________________________________________________________________________________________________

Current Medications:
__________________________________________________________________________________________________

Other important Information:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

This work was adapted from Cornerstone, New Foundations, and Division of Indian Works by PPL.

This work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 License. You are free to copy, distribute, transmit, and adapt this work
provided that this use is of a non-commercial nature, that any subsequent adaptations of the work are placed under a similar license, and that appropriate attribution
is provided where possible.

				
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