ECG Safety Plan

ECG Safety Plan

Client Code*

Date*

Step 1: Warning Signs

(Thoughts, images, mood, situation, feelings, behavior) that a crisis may be developing:

1)*

2)*

3)*

Step 2: Internal Coping Strategies

Things I can do to cope with the problem by myself (relaxation, techniques, physical activity).

1.*

2.*

3.*

Step 3: People & Social Settings that Provide Distraction

1 (Name)*

1 - Phone #

1 - I have this persons info saved in phone.

2 (Name)*

2 - Phone #

2 - I have this persons info saved in phone.

3 (Name)

3 - Phone #

3 - I have this persons info saved in phone.

4 (Place)

5 (Place)

Step 4: Professional & Agencies I can contact for help:

1. Rosecrance Crisis Line: 217-359-4141 2. National Suicide Hotline: 988 3. Suicide Hotline: 1-800-SUICIDE (784-2433) 4. Crisis Text Line: Text “HOME” to 741741 5. Pavilion Hospital: 217-373-1700 6. Carle ER: 217-383-3311 7. OSF ER: 217-337-2131 8. Suicide Prevention Lifeline: 1-800-273-8255 9. Trevor Project Hotline - Crisis Intervention for LGBTQ+ youth: 1(866)488-7386

Step 5: How can I make my environment safe?

(Removing drugs, alcohol, pills, weapons).

Step 6: What is the one thing that is most important to me and worth living for?

Answer:*

Acknowledgement

By signing below, you agree that this form was filled out together by your therapist and yourself and you fully understand the help that is available to you.

Client's Signature:*

Clinical Staff's Signature:*

1. Rosecrance Crisis Line: 217-359-4141 2. Suicide Hotline: 1-800-SUICIDE (784-2433) 3. Crisis Text Line: Text “HOME” to 741741 4. Pavilion Hospital: 217-373-1700 5. Carle ER: 217-383-3311 6. OSF ER: 217-337-2131 7. Suicide Prevention Lifeline: 1-800-273-8255 8. Trevor Project Hotline - Crisis Intervention for LGBTQ+ youth: 1(866)488-7386*

Check this box to include these numbers in your copy of responses. (Once you check this box, you must also check the next box below and please enter the client's email or your email if you are the client.)

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