Pediatric Suicide/Self-Harm Safety Plan

Patient: [legal name, preferred name if different, DOB]

Caregiver(s): [name(s) and relationship(s)]

Date Created: [date and setting]

Clinician: [name, credentials, callback number]

Copy provided to: [patient/caregiver and method]

Use this plan when warning signs appear or urges get stronger. If there is immediate danger or you cannot stay safe, call 911 or go to the Emergency Department.

Reasons for Living

(Use the youth's own words. If the youth cannot identify any, state this clearly and add caregiver-identified anchors or a plan to revisit by a specific date.)

• [person, pet, activity, goal, or future event that matters to me]
• [person, pet, activity, goal, or future event that matters to me]
• [person, pet, activity, goal, or future event that matters to me]

(If none identified) Youth unable to identify reasons today. Caregiver-identified anchors: [anchors]. Plan to revisit: [date].

Safety Plan Steps

(Start at Step 1. If you still feel unsafe after trying a step, go to the next step. Keep moving through steps until you feel safer or reach immediate help.)

Step 1 — Warning Signs

(Elicit from youth and/or caregiver; do not infer.)

• [thoughts I notice]
• [feelings or moods I notice]
• [body cues I notice]
• [behaviors I do]
• [situations or places that make it harder]

Step 2 — Coping Strategies I Can Do Alone

(List specific, doable actions. Pair each strategy with a concrete example. Include at least one nighttime option.)

• [strategy — concrete example of how I will do it]
• [strategy — concrete example of how I will do it]
• Nighttime option: [strategy that works at night]

Step 3 — People and Places for Distraction

(Safe people and places to be around without having to talk about suicidal thoughts.)

• [person or place] — [how to reach or where to go]
• [person or place] — [how to reach or where to go]

Step 4 — People I Can Ask for Help

(At least two trusted adults with contact info and a short script. If refused, document and specify alternatives.)

• [trusted adult name, relationship]: [phone/text] — Best time/way to contact: [details]
  What I will say: [brief script in youth-friendly words]
• [trusted adult name, relationship]: [phone/text] — Best time/way to contact: [details]
  What I will say: [brief script in youth-friendly words]

If I can't reach them: [backup plan]

Step 5 — Crisis Resources

• Treating clinician: [name] — [phone] (After-hours: [instructions])
• 988 Suicide & Crisis Lifeline: Call 988, text 988, or chat at 988lifeline.org
• Emergency Department: [name and address]
• Emergency: Call 911
• (Include for LGBTQ+ youth when relevant) The Trevor Project: Call 1-866-488-7386, text START to 678-678, or chat at thetrevorproject.org

Step 6 — Making the Environment Safer

(List specific actions for each relevant hazard—firearms, medications, sharps, other. Never write "means secured" without details.)

• Hazard: [item(s) to be secured]
  Action: [specific steps]
  Responsible adult: [name/relationship]
  By when: [date/deadline]
  Verification: [how completion will be confirmed]

(Repeat for each relevant hazard category)

Caregiver Plan

Supervision:

• Daytime: [who supervises, where, check-in schedule]
• Evening: [who supervises, where, check-in schedule]
• Night: [who supervises, sleep arrangement, checks]

Warning signs caregiver will watch for: [specific observable behaviors/cues]

How the youth will signal they need help: [word, phrase, gesture, or text plan]

Caregiver de-escalation supports: [calming strategies, reducing demands, privacy/supervision balance]

Escalation threshold: If [specific signs or inability to maintain safety], caregiver(s) will [call clinician / call or text 988 / go to ED / call 911].

Youth will: [commitments to using steps, asking for help, communicating about safety]

Caregiver(s) will: [commitments to supervision, maintaining means safety, check-ins]

(If applicable) Caregiver constraints and backup supports: [limitations and compensatory steps]

Follow-Up

Next appointment: [date, time, location, clinician]

Backup plan if missed: [who to contact, how to reschedule, interim supports]

Planned outreach: [who will reach out and when]

(If not yet scheduled) Scheduling responsibility: [person responsible] by [deadline]. Interim safety supports: [supports until appointment]