Client Safety Plan Form (Domestic Violence)

Structured safety planning form used by DV advocates to document a survivor's personalized escape routes, code words, safe contacts, document storage locations, and post-incident steps. Supports trauma-informed, survivor-led planning sessions.

Session and Confidentiality Notice

• Date of Safety Planning Session
  Date this plan was created or most recently updated.
• Advocate / Case Manager Name
• Program / Office Location
• Type of Safety Plan
• Client Case Number or Pseudonym
  Use your program's assigned case number or a client-chosen pseudonym. Do NOT enter full legal name here unless required by your program's policy.
• Confidentiality and voluntary participation explained to client
  Advocate confirms they have explained the limits of confidentiality (mandatory reporting obligations) and that participation is voluntary.

Current Living Situation

• Current Living Situation
• Are children present in the home?
• Number of children (if applicable)
• Are pets present in the home?
  Pets are often used as a means of coercive control. Pet safety can be included in the plan.
• Are there firearms or other weapons in the home?
  This information helps assess lethality risk per the Danger Assessment (Campbell, 2004). Presence of firearms significantly elevates homicide risk.
• Client's self-assessed danger level right now
  1 = Feels relatively safe; 10 = In immediate danger. Survivor's own assessment is the most reliable indicator.

Escape Routes and Safe Exits

• Safe exit routes from home
  Describe primary and secondary exit routes (e.g., front door, back door, window, garage). Include which doors/windows can be unlocked quietly.
• Rooms or areas to avoid during a conflict
  Identify rooms with limited exits, access to weapons, or other hazards (e.g., kitchen, garage).
• Location of pre-packed go bag or emergency items
  Where is the go bag stored? Who else knows its location? Consider a bag at a trusted person's home if home is not safe.
• Go bag contents checklist
  Select all items currently packed or planned for the go bag.
• Transportation plan if leaving quickly
• Safety plan for workplace or school
  If the abusive person knows your workplace or school, note who to alert, parking/entry adjustments, and exit routes.

Code Words and Communication Safety

• Code word or phrase to signal immediate danger
  A word or phrase the survivor can say to a trusted contact (in person, by phone, or text) that means 'I am in danger — call for help or come now.'
• Code word or phrase to signal 'I need to leave now'
• Who knows these code words?
• Phone and digital safety measures in place
  Select all measures currently taken or planned.
• Check-in plan with a trusted contact
  Describe a regular check-in schedule. If the survivor misses a check-in, what should the contact do?

Safe Contacts and Support Network

• Safe Contact List
  List trusted contacts. Include only people who are safe to contact and will not disclose your location or plans.
• Local shelter or safe house information
  Name, address (if safe to document), and phone number of local DV shelter or safe house.
• Crisis hotline numbers saved
• People who should NOT be contacted or informed
  Note any individuals who might share information with the abusive person (mutual friends, family members, coworkers).

Important Documents and Financial Safety

• Important documents — current status
  Note the location of each document or whether a copy has been secured.
• Financial safety steps taken or planned
  Select all that apply. Do NOT document account numbers here.
• Legal documents — notes
  Note the status of any protective orders, custody orders, divorce proceedings, or immigration documents.

During and After an Incident

• Steps to take during a threatening or violent incident
  Document the survivor's personalized plan: where to go, who to call, what to say to children, how to signal for help.
• Barriers to calling 911 and how to address them
  Note any concerns about calling police (immigration status, prior negative experiences, language barriers) and alternative resources.
• Steps to take immediately after an incident
• Plan for documenting abuse over time
  Describe how the survivor will safely document incidents (journal, photos, saved messages) for potential legal proceedings.
• Safety plan for children during an incident
  What should children do? Where should they go? What code word tells them to leave?
• Safety plan for pets
  Many DV shelters have pet-friendly options or partnerships with animal shelters. Document the plan for pets.

Emotional Safety and Ongoing Support

• Emotional support resources
• Activities that help the survivor feel safe and grounded
  Survivor-identified activities that support emotional regulation and wellbeing.
• Barriers to implementing this safety plan
  Note any practical, financial, cultural, legal, or emotional barriers and how the advocate can help address them.
• Next safety plan review date
  Safety plans should be reviewed regularly and after any significant change in circumstances.
• Preferred method for follow-up contact

Advocate Notes and Plan Distribution

• Lethality Assessment completed during this session
  e.g., Maryland Lethality Assessment Protocol (LAP) or Danger Assessment (Campbell).
• Lethality assessment result / risk level
• Mandatory reporting obligation triggered during this session
• Advocate session notes
  Document session observations, referrals made, and any immediate safety concerns. These notes are part of the confidential case record.
• Copy of safety plan provided to
• Advocate Signature
  Advocate signature confirms this plan was developed collaboratively with the client and that confidentiality obligations were explained.