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Run: Safety Planning Intervention Documentation

Document a collaborative safety plan that captures warning signs, coping strategies, support contacts, means restriction, and crisis steps in one place. Use ...

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Consent and Submission Details

Patient name (required)

Enter the patient's preferred legal or chosen name for this record.

Date of safety plan (required)

Date the safety plan was completed or updated.

Completed collaboratively with the patient (required)

Confirm the plan was created with the patient whenever possible.

Yes No N/A

Consent to document and share this safety plan with the care team (required)

This may include relevant behavioral health information and crisis planning details. Share only with authorized care team members.

Yes No N/A

Preferred contact method

Optional. Use only if needed for follow-up.

Warning Signs

Warning signs that a crisis may be developing (required)

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 (required)

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 (required)

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.

Yes No N/A

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 (required)

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 (required)

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.

Yes No N/A

Escalation Plan and Follow-Up

Escalation steps if risk increases (required)

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.

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