Personalized Safety Plan

The following steps represent my plan for preparing in advance for the possibility of
violence and increasing my safety. Check boxes below that apply and complete
descriptions to clarify action steps.

Part 1: Safety at home

I will tell my ________________ (counselor, advocate, etc.) about my partner and
seek the support I need to stay safe.

I will call PPL property management to change my locks.

I will review physical safety in my home. A safe place in my home is

___________________.

I will call 911 when I don’t feel safe.

I will meet with property management to have my partner removed from the
lease (if applicable).

I will inform the following people that my abuser does not reside with me, and
they should call the police if the abuser is observed near my residence/if they hear
suspicious noises coming from my house.
a. Neighbor __________________
b. Friend ____________________
c. Other ____________________

If I have to leave my home, I can go to ________________________. If I cannot go

there, I will go to ______________________.

In case I have to leave, I will have the following available in one safe place:
important papers such as birth certificate, social security cards, insurance
information, school and health records, welfare and immigration documents,
and divorce or other court documents
credit cards, back account number and ATM cards, and some money
extra set of keys
medication and prescriptions
phone numbers and addresses for family, friends, doctor, lawyers and
community agencies
clothing and comfort items for you (and your children)
 Other things I can do to stay safe are:
___________________________________________________________________________________
___________________________________________________________________________________
__

Part 2: Order for Protection

I will obtain an order for protection and can ask ________________ if I need
assistance.

I will call the domestic violence hotline if I am not sure how to register for a
protection order.

If I have a protection order, I can keep a copy ____________________ (location) and

will call in any violations. I will also check with the police and county sheriff’s
departments where I live to confirm my order is on file. The numbers are
_____________ (police) and ________________ (sheriff).

I can call PPL property management to change my locks, as well as request for a
building trespass after I have a protection order in place.

I will inform my advocate _________________ and employer _____________________ that

I have a protection order in effect.

If my partner violates the protection order, I will call the police and report it. I will
call my advocate/counselor and/or tell the courts about the violation.

If my protection order gets destroyed, I can go to the County Courthouse and get
another copy.

If I have to communicate with my abuser, the safest way for me to do so is

__________________.

If I feel threatened I can go into a store, gas station, restaurant to call

__________________ for help.

Part 3: Safety for my children (if applicable)

I will let those who care for my children know that my abuser is not permitted to
pick them up, and I will make clear who has permission to do so. I will inform:
1. School_____________________________________
2. Day Care___________________________________
3. Babysitter__________________________________
4. Teacher____________________________________
5. Others_____________________________________

_______________ is my code word to let my children and friends know to call for help.
 I will teach my children to call to me and _________________ (friend/other) in the
event my abuser takes the children.

When I am frustrated with my children, I will move to a safer room such as

____________________.

If I need a break from my children or if my children need a safe place out of the
home, ______________ is available to provide short-term (30min-2hour) care.
____________________ is available to provide overnight care. I can also use the Crisis
Nursery – 763-591-0100.

What age-appropriate information do I want to teach my child/children? (Examples:

911, phone numbers to call, neighbors to go to, how to talk to my child/children
about violence).
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___

Part 4: Emotional Health

If I feel depressed or anxious, steps I can take are _______________________________.

If I am thinking about returning to a potentially unsafe situation, I can take the

following steps:
_________________________________________________________________________________.

I can tell myself "___________________________________________" when I feel people

are trying to control or abuse me.

I can call the following people and/ or places for support:

___________________________________________________________________________________.

Things I can do to make me feel stronger are:

___________________________________________________________________________________.

Part 5: Drug and Alcohol Use (if applicable)

I can honor my commitment to sobriety and abstain from use.

If I am having strong cravings to use, steps I can put in place to protect myself
(and my child/children):
___________________________________________________________________________________
___________________________________________________________________________________
__
 In the event PPL has concerns regarding my chemical health they should contact:
________________________, _________________________ to pick up and provide care for
my children in my absence or inability to care for my children.

I can review my safety plan periodically. By creating one, I have taken a

proactive step, and I will continue to be conscious of my own safety (and that
of my children).

___________________________________________________
______________________________ Individual Signature
DATE
___________________________________________________
______________________________ PPL Staff Signature
DATE

This work was adapted from Cornerstone, New Foundations, and Division of Indian Works by PPL.

This work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 License. You are free to copy, distribute,
transmit, and adapt this work provided that this use is of a non-commercial nature, that any subsequent adaptations of the work are
placed under a similar license, and that appropriate attribution is provided where possible.
 Other Important Information

Domestic Violence Hotline (866) 223-1111 (toll free)

Advocate ___________________________ Phone number

____________________________

Employer ___________________________ Phone number

____________________________

School _____________________________ Phone number

____________________________

School _____________________________ Phone number

____________________________

School _____________________________ Phone number

____________________________

Sponsor ___________________________ Phone number ____________________________

Property Manager ____________________ Phone number

____________________________

Bus Line ___________________________ Phone number ____________________________

Case Manager _______________________ Phone number

____________________________

Day Care ___________________________ Phone number

____________________________

My Social Security Number is ___________________________.

My child(ren)’s Social Security Numbers are:

___________________________, ___________________________, ___________________________,
___________________________, ___________________________, ___________________________.

Bank Account Information:

_________________________(name) , ___________________________ (account #)

Other Important Information:

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
___

This work was adapted from Cornerstone, New Foundations, and Division of Indian Works by PPL.

This work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 License. You are free to copy, distribute,
transmit, and adapt this work provided that this use is of a non-commercial nature, that any subsequent adaptations of the work are
placed under a similar license, and that appropriate attribution is provided where possible.