Personal Safety Plan printable pdf download

Name: _______________________________

DATE: ____________

Facility: ______________________________

Personal Safety Plan

(Modified for use in Limited Mental Health Assisted Living Facilities)

You can document on this form suggested calming strategies IN ADVANCE of a crisis. You can list things that are

helpful when you are under stress or are upset. You can also identify things that make you angry. Staff and

individuals receiving services can enter into a “partnership of safety” using this form as a guide to assist in your

treatment plan. The information is intended only to be helpful; it will not be used for any purpose other than to

help staff understand how to best work with you to maintain your safety or to collect data to establish trends. This

is a tool that you can add to at any time. Information should always be available from staff members for updates

or discussion. Please feel free to ask questions.

1. My Favorite Things are: What are things that you like? How would you like someone to let you know that they are

proud of you or that you did a good job?

Food, specify:

Books, specify:

Extra time spent doing something? Specify:

Art supplies, specify:

Music, CD’s? I-Tunes?

Games, specify:

Special privilege:

Picking the movie for movie night.

Picking out the menu for dinner.

Other? (Please list below)

Sports Equipment, specify:

1b.What would you like to hear someone tell you that would make you feel more respected and appreciated?

__________________________________________________________________________________________

2. Calming Strategies: It is helpful for us to be aware of things that help you feel better when you’re having a hard time.

Please indicate (5) activities that have worked for you, or that you believe would be the most helpful. If there are other

things that work well for you that we didn’t list, please add them in the box marked “Other”. We may not be able to offer all

of these alternatives, but we would like to work together with you to determine how we can best help you while you’re here.

Listen to music

Exercise

Read a book

Pace in the halls

Wrapping in a blanket

Have a hug with my consent

Write in a journal

Drink a beverage

Watch TV

Dark room (dimmed lights)

Talk to staff

Medication

Talk with peers on the unit

Read religious or spiritual material

Call a friend or family member

Write a letter

Voluntary time in the quiet room/comfort room

Hug a stuffed animal

Take a shower

Do artwork (painting, drawing)

Go for a walk with staff

Other? (Please list below)

3. What are some of the things that make you angry, very upset or cause you to go into crisis? What are your

“triggers”?

Being touched

Called names or made fun of

Security in uniform

Being forced to do something

Yelling

Physical force

Loud Noise

Being isolated

Contact with person who is upsetting

Some else lying about my behavior

Being restrained

Being threatened

Personal Safety Plan

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