Below is a template of a Safety Plan. You can also download a fillable PDF version of the Safety Plan to keep on your computer or phone ready for immediate use.
Contact Information
| Name | Mobile Ph. | Office Ph. | Home Ph. | ||
|---|---|---|---|---|---|
| Patient | |||||
| Family Contact |
Health Care Professionals
| Name | Phone | Email/Address | |
|---|---|---|---|
| Psychiatrist | |||
| Therapist | |||
| HD Physician | |||
| Social Worker |
People to call for help
| Name | Phone | Email/Address | |
|---|---|---|---|
| Neighbor | |||
| Family Member | |||
| Friend | |||
| Other |
Strategies
| Strategies to keep the home environment safe: | |
|---|---|
| 1 | |
| 2 | |
| 3 |
| Strategies to de-escalate a tense situation: | |
|---|---|
| 1 | |
| 2 | |
| 3 |
| Items I need to have with me if I leave: | |
|---|---|
| 1 | |
| 2 | |
| 3 |
| Things the person with HD might need: | |
|---|---|
| 1 | |
| 2 | |
| 3 |
| Emergency contacts for children: | |
|---|---|
| 1 | |
| 2 | |
| 3 |
Emergency Resources
Call 911
-
Ask for CIT Trained Officer
-
Explain the person has Huntington’s disease and request to send the “Information for First Responders”
-
Mobile Crisis Service phone# ________________________
-
Local Crisis Center phone # _________________________
-
Other phone # ____________________________________
-
