PLEASE PRINT AND SHARE WITH A TRUSTED
FRIEND OR HEALTHCARE PROVIDER
                                MY PLAN TO PREVENT SELF-HARM

I agree that whenever I begin to think of harming myself or others, I will not attempt to act upon those
thoughts and follow my plan of care below.

RESOURCES (Trusted People I Can Talk With)














MY PERSONAL SAFETY PLAN

















My Signature: ________________________________________________         Date: ____________________



Witness Signature: ___________________________________________         Date: _____________________


                     KEEP THIS SAFETY PLAN WITH YOU OR PLACE IT WHERE YOU CAN READ IT QUICKLY
Name
Telephone Number
Camden Emergency Services
911
(Counselor's Name):
 
(Doctor's Name):
 
(Family Name):
 
(Friend's Name):
 
(Friend's Name):
 
GOAL:
 "I will not act upon thoughts of harm to myself or to others."
OJBJECTIVE:
 To prevent acting upon thoughts of harm to myself or to others, I
will do any one of the following steps in my safety plan:
INTERVENTIONS:
(Action steps or
coping skills in my
safety plan)
 1.  Let at least one of those persons listed above know what I am
thinking / how I am feeling
2.  
3.  
4.