April 7th, 2022 
CCMH/558 v3
Client Safety Plan
CCMH/558 v3
Page 6 of 6
from SAMHSA in 175–250 words. Use full sentences and appropriate grammar.
Support your assessment with appropriate terminology from the DSM-5.
Part 2: Client Safety Plan
Develop an ongoing safety plan for this client to follow once the initial intervention is complete. Use the Client Safety Plan section of the form to document the parts of your plan using clear language the client can understand if in crisis.
Explain the potential cultural differences between counselor and client that might influence the professional counseling relationship in this scenario. Explain how your safety plan incorporates these cultural considerations to benefit the client’s experience with the treatment process.
Note: Your Client Safety Plan and cultural explanations should be 350–450 words.
Format your citations and references according to APA guidelines.
Part 1: Suicide Risk Assessment
Step 1: Identify Risk Factors
What risk factors exist for this individual? Which factors can be modified to reduce risk?
Risk Factors | Notes |
Precipitants and stressors · Recent trauma, triggering events (real or anticipated), another prior crisis · Medical illness, intoxication · Family or interpersonal turmoil, history of physical or sexual abuse, social isolation · Change in treatment or treatment provider, or discharge from psychiatric hospital | Enter notes here. |
History of risk factors · Attempts to die by suicide · Self-injurious behavior · Psychiatric disorders, comorbidity, and mental health treatments · Attempts of family members to die by suicide · Family diagnosed with Axis 1 psychiatric disorders that required hospitalization | Enter notes here. |
Enter notes here. | |
Lethal Access · Access to firearms or other lethal methods | Enter notes here. |
Step 2: Identify Protective Factors
Which factors can be enhanced to protect the client? Note: These protections may not counteract high risk factors.
Protective Factors | Notes |
Internal · Ability to cope with stress or frustration · Spiritual beliefs | Enter notes here. |
External · Social supports · Responsibility to loved ones, children, or pets · Positive therapeutic relationships | Enter notes here. |
Step 3: Conduct Suicide Inquiry
Has this individual had any ideations, plans, behaviors, or intentions to die by suicide? To what extent does the client intend to carry out their plan? How lethal or self-injurious do they think their plan would be? What are their reasons to live or die?
Notes | |
Ideations · Frequency, intensity, and duration of suicidal thoughts and ideations in: a. the last 48 hours b. the past month c. the worst ever | Enter notes here. |
Plan · Time · Place · Lethality of their method · Availability of their method · Ways they have prepared for death | Enter notes here. |
Behavior · History of attempts (and aborted attempts) to die by suicide · Rehearsal behaviors for suicide vs. non-suicidal self-injurious actions | Enter notes here. |
Intent · Extent to which the client expects to carry out the plan · Extent to which the client believes it to be lethal versus self-injurious | Enter notes here. |
Special Considerations · For youth and parents/guardians of minors: ask about evidence of suicidal thoughts, plans, or behaviors as well as changes in mood, behaviors, or dispositions · When indicated, or for character disordered or paranoid males dealing with loss or humiliation: ask about 4 areas above and conduct homicide inquiry | Enter notes here, if applicable. |
Step 4: Determine Risk Level / Intervention
After using your best judgment to assess the client in Steps 1-3, what risk level do you think they are demonstrating?
Risk Level | Risk Factor | Protective Factor | Suicidality | Possible Interventions |
High | Psychiatric diagnoses with severe symptoms or acute precipitating event | Protective factors not relevant | Potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal | · Admission generally indicated unless a significant change reduces risk · Take suicide precautions |
Moderate | Multiple risk factors | Few protective factors | Suicidal ideation with plan, but no intent or behavior | · Admission may be necessary depending on risk factors · Develop crisis plan · Give emergency and crisis numbers |
Low | Modifiable risk factors | Strong protective factors | Thoughts of death, no plan, intent, or behavior | · Outclient referral, symptom reduction · Give emergency and crisis numbers |
Step 5: Document
1. What do you think is the client’s risk level? Justify your reasoning for this determination.
Enter your response.
2. What intervention do you recommend that addresses the current risks? What is your plan for treatment? What can you and the client do to reduce these risks (e.g., medication, setting, psychotherapy, E.C.T., contact with significant others, consultation)?
Enter your response.
3. Provide firearms instructions, if relevant.
Enter your response, or N/A if not applicable.
4. What is the follow-up plan? In the case of youths, what roles should the parent/guardian have?
Enter your response.
Part 2: Client Safety Plan
The client should refer to this safety plan in times of crisis.
Step 1: Signs of Crisis
· How do you know that a crisis might be developing?
· What warning signs (such as thoughts, images, moods, behaviors, or other situations) are you experiencing?
Enter your response.
Enter your response.
Enter your response.
Step 2: Coping Activities
· What are 3 activities I can do to take my mind off my problems without contacting someone else?
· What independent coping mechanisms (such as relaxation techniques, physical activity, reading, or other internally guided actions, etc.) can I do to remain safe?
Enter your response.
Enter your response.
Enter your response.
Step 3: Social Distractions
· What are the names and contact information for 2 people who can provide distraction?
· Where are 2 places I can go for socialization to distract me?
Name and Phone Number: Enter your response.
Name and Phone Number: Enter your response.
Place: Enter your response.
Place: Enter your response.
Step 4: Call for Help
· Who are 3 people I can ask for help? How do I reach them?
Name and Phone Number: Enter your response.
Name and Phone Number: Enter your response.
Name and Phone Number: Enter your response.
Step 5: Professional Support
· Who are the professionals I can contact during a crisis?
· What agencies can help me? How do I reach them?
Clinician Name, Phone Number, and Emergency Number: Enter your response.
Clinician Name, Phone Number, and Emergency Number: Enter your response.
Local Urgent Care Services Name, Address, and Phone Number: Enter your response.
1. Suicide Prevention Lifeline Phone: 1-800-273-TALK (8255)
Step 6: Safe Environment
· What are 2 steps that I can take to make my environment safe?
· Where can I go—in public or in private—to feel safe? If I leave home, what should I take with me?
Enter your response.
Enter your response.
Step 7: Personal Strengths
· What 3 qualities do I have that will help me remain resilient during a crisis? (When I am upset, I can redirect my energy and focus my attention on being ___ to help me cope.)
Enter your response.
Enter your response.
Enter your response.
Step 8: Focus
· What is the 1 thing that is most important to me and worth living for?
Enter your response.
References
Enter your references for both Parts 1 and 2 in APA format.
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Copyright 2021 by University of Phoenix. All rights reserved.
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