Personalized Safety Plan

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

Step 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 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:

____________________________________________________________________________________
____________________________________________________________________________________

Step 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).

Project for Pride in Living

  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.

Step 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:
d. School_____________________________________
e. Day Care___________________________________
f. Babysitter__________________________________
g. Teacher____________________________________
h. Others_____________________________________

 _______________ is my code word to let my children and friends know to call for help.

 I will teach my children to make a collect call to me and to _________________ (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, _________________________________________ has my

permission to provide short-term (30min-2hour) care for____________________________________.

 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).
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Step 4: 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, I will put the following services in place (to protect my
child/children):
____________________________________________________________________________________
____________________________________________________________________________________
Project for Pride in Living
  In the event Project for Pride in Living has concerns regarding my chemical and mental health they
should contact:
1.__________________________________________________________________________________
2.__________________________________________________________________________________
to pick up and provide care for my children in my absence or inability to care for my children.

Step 5: Emotional Health

 If I feel depressed and ready to return to a potentially violent situation, I can
__________________________________________________________________________________

 I will use "I can..." statements and I will be assertive with people.

 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:

____________________________________________________________________________________

 (If applicable) I can call ________________________ to provide my children with a safe environment.

I understand that this information will be shared only with staff or their consultants who need my information
to assist the administration of the program to better support me (and my child/children).

 ___________________________________________________ ______________________________
Individual Signature DATE

 ___________________________________________________ ______________________________
PPL Staff Signature DATE

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).

Project for Pride in Living

 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:

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Project for Pride in Living
Project for Pride in Living