Professional Documents
Culture Documents
Personalized Safety Plan
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.
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 ____________________
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)
I will call the domestic violence hotline if I am not sure how to register for a
protection order.
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.
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.
_______________ is my code word to let my children and friends know to call for help.
If I am having strong cravings to use, I will put the following services in place (to
protect my child/children):
___________________________________________________________________________________
___________________________________________________________________________________
__
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.
I will use "I can..." statements and I will be assertive with people.
___________________________________________________
______________________________ Individual Signature
DATE
___________________________________________________
______________________________ PPL Staff Signature
DATE
Other Important Information
____________________________
____________________________
____________________________
____________________________
____________________________
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