Safety Plan Template
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1STUDENT SAFETY PLAN
Student Name: ____________________________________ Date: __________________
Person Writing Plan: ________________________________ Position: _______________
Concern for Safety: _____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Strategies and Coping Skills for Remaining Safe: (list including who is responsible) *____________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Resources Available to Student: (list who student can talk to and where to go) * _______________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Outside Recommendations and Other Important Things to Know: * _________________________
______________________________________________________________________________
______________________________________________________________________________
This plan will be reviewed by the counselor and student every ________ week(s) until concern no
longer exists.
By signing this plan, the student understands the right to confidentiality is not protected in matters
concerning safety of self or others. This student has been informed that at least the school
administration, his/her classroom teachers, student services personnel, and his/her guardian will be
or have been informed of this plan.
SIGNATURE :
POSITION:
DATE:
_________________________
_____student_________
_______________
_________________________
_____counselor_______
_______________
_________________________
_____administrator_____
_______________
_________________________
_____parent / guardian__
_______________
_________________________
____________________
_______________
_________________________
____________________
_______________
_________________________
____________________
_______________
Review Date(s): (date and initial)
__________ __________ __________ __________
Date Plan Discontinued (no further safety concerns exist): (date and initial)
__________
* Use back of page if additional space is needed.
220 Campbell Road ● Mocksville, NC 27028 ● 336-751-2229 ● Fax 336-751-1364
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