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Run: Client Safety Plan Form (Domestic Violence)

A domestic violence client safety plan form for documenting escape routes, code words, safe contacts, document storage, and post-incident steps. Use it to bu...

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Session and Confidentiality Notice

Date of Safety Planning Session (required)

Date this plan was created or most recently updated.

Advocate / Case Manager Name (required)

Program / Office Location

Type of Safety Plan (required)

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 (required)

Advocate confirms they have explained the limits of confidentiality (mandatory reporting obligations) and that participation is voluntary.

Yes No N/A

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.

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