"Personal Safety Plan"
PERSONAL SAFETY PLAN CLIENT NAME: CLIENT ID #: If I am in crisis: 1. My case manager’s name is: Telephone #: Crisis/Afterhours #: 2. Things that upset me or trigger my emotions are: 3. My warning signs that will let others know I am having a hard/difficult time or I am upset are: 4. If I am having a hard time or expressing anger inappropriately, the following coping skills work best for me. These are my preferred interventions: taking my medication voluntary time out in a quiet room sitting by staff reading talking with staff exercising going for a walk talking with my case manager writing in a journal being silent listening to music talking with a peer watching TV being given an opportunity to be heard calling a friend being outside deep breathing exercises talking with parent/guardian/significant other praying other 5. Please notify: Name & Relationship: Telephone #: Client signature: Date: Staff signature: Date: SCDMH FORM FEB. 2011 C-203