Life Safety Plan Template	

Step 1:	Warning signs (thoughts, images, mood, situation, behavior) that a crisis may be developing:	
1.   	
2.   	
3.   		
Step 2:	Internal coping strategies – Things I can do to take my mind off my problems without contacting another person (relaxation technique, physical activity):	
1.   	
2.   	
3.   		
Step 3:	People and social settings that provide distraction:	
1.	Name 	Phone 	
2.	Name 	Phone 	
3.	Place 	4. Place 		
Step 4:	People whom I can ask for help:	
1.	Name 	Phone 	
2.	Name 	Phone 	
3.	Name 	Phone 		
Step 5:	Professionals or agencies I can contact during a crisis:	
1.	Clinician Name 	Phone	 Clinician Pager or Emergency Contact #  		
2.	Clinician Name 	Phone	 Clinician Pager or Emergency Contact #  		
3.	Local Urgent Care Services 	                                                                                                          Urgent Care Services Address 	                                                                                                    Urgent Care Services Phone 	 
4.	Suicide Prevention Lifeline Phone: 1-800-273-TALK (8255)	
Step 6:	Making the environment safe:	
1.   	
2.