FLORIDA
Therapy Services, Inc.
CRISIS / SAFETY PLAN
Client Name:
Date:
If I feel I am going to harm myself or others, I will call 911.
I agree to not harm myself or anyone else. I agree to get rid of things that I could use to hurt or kill myself or others.
If I am having suicidal thoughts or homicidal / violent thoughts, I will call the FTS 24 hour emergency phone number. I
know that I may call that number any time 24 hours per day / 7 days per week.
If I am feeling depressed, upset, angry, frustrated, overwhelmed or anxious, I will call:
_________________________________________________________________________________________
(Name and phone number of friend, family member or significant other)
If I am unable to reach that person, I will call the FTS 24 hour emergency phone number: 1-866-539-6993.
There are things that can help you feel better when you’re feeling depressed, upset, angry, overwhelmed or anxious.
Please check the activities that have worked for you, and that you believe would be the most helpful. If there are other
things that work well for you that are not on the list, please add them to the list.
Make a positive statement about myself every day
Read a book
Wrap in a blanket
Write in a journal
Watch TV
Talk to a relative
Talk to a friend
Take a shower
Go outside and enjoy nature
Add your own activity:
Write a letter
Hug a stuffed animal
Paint, draw, color
Walk on the beach
Take my medication
Go for a walk
Listen to music
Have a snack
Attend a support group
If I am feeling depressed, upset, angry, frustrated, overwhelmed or anxious, I will use the activities I checked above to
comfort myself. If these activities don’t work, I will call the numbers noted above.
Signed: _____________________________________________________________________________
Witness: _____________________________________________________________________________
Client ID #: ______________________________________________
Confidential
Revised 9/11/14
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