Personal Safety Plan (Page 2 of 2) in pdf

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Personal Safety Plan

(page 2)

4. Signals of Distress: Please describe your warning signals, for example, what you know about yourself, and what other

people may notice when you begin to lose control. Check those things that most describe you when you’re getting upset.

This information will be helpful so that together we can create new ways of coping with anger and stress:

Sweating

Clenching teeth

Crying

Not taking care of self

Breathing hard

Running

Yelling

Clenching fists

Hurting others:

Swearing

Throwing Objects

Not eating

Pacing

Being rude

Injuring self: (Please be specific)

Other? (Please list below)

5. Preferences Regarding Gender and Others: Do you have any preferences or concerns regarding who serves you

when you are upset or angry?

Women staff_________

Men staff_____________ No preference_________ Language______________________

Ethnicity________________________

Culture ____________________

Of a particular religion________________

6. Preferences Regarding Physical Contact: We would like to know about your preferences regarding physical

contact. For example, you may not like to be touched at all or you may find it helpful to have a hug or be touched

appropriately when you are upset.

Do you find it helpful to be hugged or touched appropriately when you are upset?

Yes___ No___ Comments:___________________________________________________

7. Medical Conditions: Do you have any physical conditions, disabilities, or medical problems such as asthma, high

blood pressure, back problems, etc., that we should be aware of when caring for you during an emergency situation?

________________________________________________________________________________________

8. Room Checks:

Room checks are done at night to make sure you are okay. In order to make room checks as non-

intrusive as possible is there anything that would make room checks more comfortable for you?

__________________________________________________________________________________________________

9. Anything Else? Is there anything else that would make your stay easier and more comfortable? For example do you

have any special issues like cultural, diet, sexual preference, appearance, etc. that you think could contribute to

misunderstandings or cause problems for you? Please describe:

__________________________________________________________________________________________________

Personal Safety Plan Page 2

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