Crisis/Safety Plan (Suicide/Self-Harm/Overdose Risk)

Header (clinician-facing, compact)

• Date/Time: [Date and time of plan creation]
• Setting: [in-person / telehealth / phone]
• Author: [Author name and role/title]
• Indication: [Why plan created today; risk domains addressed: suicide / self-harm / overdose]
• Plan given to patient: [yes / no]; Format: [paper / patient portal / email / text]

How to Use This Plan

• Use this plan when warning signs start. Go step by step.
• Emergency override: If I might act on thoughts to hurt myself, or if I or someone else may be overdosing, call 911 now.
• For crisis support anytime: call or text 988.
• If I can't stay safe with these steps, go to the emergency department.

Step 1: My Warning Signs & Triggers

• Thoughts: [1–3 thought warning signs in patient's own words]
• Feelings: [1–3 feelings that signal risk]
• Behaviors: [1–3 actions that show patient is not okay]
• Body sensations: [1–3 body cues patient notices]
• Triggers or situations: [Specific people, places, or events that raise risk]

(If patient has difficulty identifying warning signs, note "Identified with clinician support:" and list what was determined collaboratively. Include at least 1–3 individualized items; avoid generic lists.)

When I notice these warning signs, I will move to Step 2.

Step 2: Things I Can Do on My Own

• I will [specific coping strategy patient will actually use]
• I will [specific short activity that soothes or distracts]
• I will [simple grounding routine that helps patient feel safe and present]
• I will [limit-setting step if needed]

(Include 3–5 strategies. Keep each action brief, specific, and doable alone. Use patient's words.)

Step 3: People & Places That Help

Safe places I can go:

• I will go to [safe place]. I will get there by [transportation plan].

People for distraction/company (to be around without disclosing crisis):

• [Name] — [phone]

People I can ask for help:

• [Name] — [phone]
  • What I will say: "[Brief script in patient's words]"
  • If no answer: [Next step: call/text next person / call 988 / go to safe place]

(If no safe places or supports identified, document this explicitly and emphasize Step 4 resources.)

Step 4: Professional & Emergency Resources

• 988 Suicide & Crisis Lifeline: Call or text 988 anytime.
• My treatment team: [Clinician name], [phone]; [after-hours process]
• Nearest emergency department: [Name and address]

Decision rules:

• If I can't commit to staying safe → call 988 now.
• If an attempt is in progress or overdose is suspected → call 911 or go to the ED immediately.

Step 5: Making My Environment Safer

(For each applicable means category, document current access, specific action to reduce access, responsible person, and timeline. Do not document "no access" unless explicitly assessed.)

• Firearms: Access: [describe]. Action: [specific step]. Responsible: [name]. Timeline: [today / within 24 hours].
• Medications: Access: [describe]. Storage plan: [lockbox / limited quantities / supervised by trusted person]. Responsible: [name]. Timeline: [today / within 24 hours].
• Sharps: Access: [describe]. Action: [specific step]. Responsible: [name]. Timeline: [today / within 24 hours].
• Other means: [Describe item]. Action: [specific step]. Responsible: [name]. Timeline: [today / within 24 hours].

If overdose risk is present:

• Naloxone: Available? [yes / no]. Location: [where kept]. Who can use it: [names]. If not available → Plan to obtain: [where/how; by when].
• Plan to avoid using alone: Check-in buddy: [name, phone]. Check-in plan: [how and when].

Follow-Up Plan

My commitments:

• I will use this plan in order when warning signs start.
• I will complete means-safety steps by: [date/time].
• I will attend follow-up on: [date/time].

Clinical team commitments:

• Next appointment: [date/time; modality].
• Planned outreach/check-in: [who, how, when].
• Referrals made: [service, contact info, status].

If this plan isn't working: I will [call or text 988 / go to the ED / contact backup support: name, phone].

Collaboration Statement

Plan created collaboratively with patient. Patient reviewed and edited the plan; wording reflects patient preferences. Patient demonstrated understanding of when and how to use the plan.

(Do not frame as a "contract for safety"—this is a collaborative action plan, not a binding agreement.)