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 Designed to replace outdated no-harm contracts with a practical safety plan.

Consent and Submission Details

• Patient name
  Enter the patient's preferred legal or chosen name for this record.
• Date of safety plan
  Date the safety plan was completed or updated.
• Completed collaboratively with the patient
  Confirm the plan was created with the patient whenever possible.
• Consent to document and share this safety plan with the care team
  This may include relevant behavioral health information and crisis planning details. Share only with authorized care team members.
• Preferred contact method
  Optional. Use only if needed for follow-up.

Warning Signs

• Warning signs that a crisis may be developing
  List the patient's early warning signs in their own words when possible.
• Recent triggers or stressors
  Optional. Include only factors relevant to the current safety plan.

Internal Coping Strategies

• Internal coping strategies
  Add one strategy per item. Focus on actions the patient can do independently.
• Places or activities that help the patient feel safer
  Optional. Include calming environments, routines, or grounding activities.

Support Contacts

• Support contacts
  Add trusted people the patient can contact. Include only information needed to reach them.
• Patient permission to contact listed supports if risk escalates
  Use only if your workflow requires outreach and the patient has agreed.

Professional and Crisis Resources

• Primary clinician or clinic contact
  Optional. Include the most appropriate non-emergency clinical contact.
• After-hours or on-call contact
  Optional. Include only if available and appropriate.
• Crisis resources
  Select the crisis resources reviewed with the patient.
• Notes about how to access crisis resources
  Optional. Include location, hours, or instructions relevant to the patient.

Means Restriction and Environmental Safety

• Means restriction steps agreed upon
  Describe specific, practical steps such as safe storage, temporary transfer, or limiting access. Avoid unnecessary detail.
• Person responsible for implementing safety steps
  Optional. Enter the patient, family member, or other agreed support person.
• Follow-up needed to confirm means restriction steps
  Check if the care team should verify completion at a later date.

Escalation Plan and Follow-Up

• Escalation steps if risk increases
  Document the sequence of actions the patient should take if distress worsens.
• Planned follow-up date
  Optional. Use if a follow-up review is scheduled.
• Clinician or staff member who reviewed the plan
  Optional. Useful for audit trail and care coordination.