SCC Safety Plan

To ensure your safety, please identify your support team before an emergency arises. To ensure your safety, please identify your support team before an emergency arises. 

(Please fill this form out and bring it back to your next appointment)

Name Name * First Last
Date Date * / MM / DD YYYY
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone * - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Email *
Employer
Phone Phone - ### - ### ####
SCC Contact Phone SCC Contact Phone - ### - ### ####
Phone Phone - ### - ### ####
Physician _
Phone Phone - ### - ### ####
Psychiatrist: Dr.
Phone Phone - ### - ### ####
If I need someone to talk to, I will call:
1. Family 1. Family First Last
Phone Phone - ### - ### ####
2. Family 2. Family First Last
Phone Phone - ### - ### ####
3. Family 3. Family First Last
Phone Phone - ### - ### ####
4. Family 4. Family First Last
Phone Phone - ### - ### ####
5. AA/NA Sponsor (if applicable) 5. AA/NA Sponsor (if applicable) First Last
Phone Phone - ### - ### ####
6.Church (Pastor, Counselor, Prayer Line) 6.Church (Pastor, Counselor, Prayer Line) First Last
Phone Phone - ### - ### ####
If I have feelings that I might harm myself, cause harm to others or have feelings of suicide, I will call:
1. Local Mental Health
Phone Phone - ### - ### ####
Local Crisis Line
Phone Phone - ### - ### ####
Local ER
Phone Phone - ### - ### ####
If I have a medical emergency, I will call:

911 for an ambulance to the nearest Emergency/Hospital

SCC Safety Plan

SCC Safety Plan

If I need someone to talk to, I will call:

If I have feelings that I might harm myself, cause harm to others or have feelings of suicide, I will call:

If I have a medical emergency, I will call: