Safety Planning Intervention Documentation

Collaborative behavioral health form to document warning signs, coping strategies, support contacts, means restriction, and crisis resources. Designed to replace outdated no-harm contracts with a practical, patient-centered safety plan.

Submission Notice

• Patient consent to document this safety plan in the clinical record
  Confirm the patient understands what will be documented and how it will be used for care coordination and follow-up.
• Purpose of this safety plan
• If other, describe the purpose
• Completed collaboratively with the patient
  Indicate whether the plan was developed together with the patient rather than completed unilaterally.

Patient and Encounter Details

• Patient name
• Date of birth
  Collect only if needed to correctly identify the patient in the record.
• Medical record number
  Optional identifier for internal record matching.
• Encounter date
• Encounter setting

Warning Signs and Triggers

• Warning signs or triggers
• Additional notes about warning signs
  Use this field for brief context, patterns, or examples that help the patient recognize escalation.

Internal Coping Strategies and Social Distraction

• Internal coping strategies
• People or places that provide healthy distraction
• Barriers to using coping strategies
  Document any barriers and how the patient agreed to address them.

Support Contacts and Professional Resources

• Support contacts
• Professional crisis resources
• Preferred contact method for follow-up

Means Restriction and Environmental Safety

• Means restriction discussed with the patient
• Agreed means restriction steps
• Safe storage or temporary transfer of high-risk items agreed
• Support person involved in means restriction plan
  Collect only if the patient consents and it is needed for follow-up.

Crisis Escalation, Follow-Up, and Attestation

• What the patient will do if coping strategies are not enough
  Include the agreed sequence for contacting supports, professional resources, or emergency services.
• Follow-up date
• Follow-up owner
  Person or team responsible for follow-up outreach.
• Clinician attestation
  Confirm the plan was reviewed, documented accurately, and entered into the record.
• Clinician name
• Clinician role