Sensory Safety Plan Name:

Warning Signs: What are some of the things that indicate I am becoming anxious or upset?
□ Crying □ Speaking loudly or rudely

□ Shortness of breath □ Racing thoughts

□ Rocking □ Swearing

□ Shaking □ Sweating

□ Pointing finger/ waving arms □ Inability to sit still

□ Clenching fists or teeth □ Racing heart

□ Isolating self from others □ Headache/ tension in body

□ Bouncing legs □ Pacing/ walking

□ Having bad thoughts about self or others □ Butterflies or sick feeling in stomach

□ Substance Use □ Irritable

□ Laughing loudly □ Change in eating or sleeping

□ Finding it hard to think □ Change in social media use

□ Acting out of character (please explain) □ Other (please list)

Triggers: What are some of the things that can trigger me to feel upset? (Please elaborate)
□ Cravings

□ Conflict

□ Reminders/ memories from past

□ Not feeling safe

□ Distressing thoughts or nightmares

□ Change in routine

□ Particular times of day

□ Particular times of year

□ Not having control

□ Particular people

□ Other…
USING OUR SENSES TO CALM AND SOOTHE
Visual Preferences: What I like, really dislike and what is useful to calm me
like dislike Useful to like dislike Useful
calm to calm

Bright/Intense light □ □ □ Open curtain □ □ □

Natural light □ □ □ Closed curtain □ □ □

Dim light/darker □ □ □ Watch a movie/tv □ □ □

Clutter/No clutter □ □ □ Reading □ □ □

Familiar items (specify) □ □ □ Art and craft □ □ □

Busy environment/people □ □ □ Puzzles, card games □ □ □

around

Sound Preferences: What I like, really dislike and what is useful to calm me
like dislike Useful to like dislike Useful
calm to calm

Loud/ sudden noise □ □ □ Playing instruments □ □ □

High pitched noise □ □ □ Ear plugs □ □ □

Whispering □ □ □ Guided relaxation □ □ □

Silence □ □ □ Nature Sounds □ □ □

Background noise/white □ □ □ Listening to music □ □ □

noise

Touch and Body Preferences: What I like, really dislike and what is useful to calm me
like dislike Useful to like dislike Useful
calm to calm

Temperature – cool/warm □ □ □ Fidget item or stress ball □ □ □

Cold or hot shower □ □ □ Lying on bed □ □ □

Wrapped in a blanket □ □ □ Ice pack/ cool wash cloth □ □ □

Brush/play with my hair □ □ □ Being by myself □ □ □

Going for a walk □ □ □ Deep Breathing □ □ □

Pacing □ □ □ Hugging a pillow □ □ □

Human touch (e.g. hug) □ □ □ Distraction □ □ □

Writing/drawing □ □ □ Massage □ □ □

Exercising □ □ □ Gentle Stretching □ □ □

Taste and Smell: What I like, really dislike and what is useful to calm me
like dislike Useful to like dislike Useful
calm to calm

Hot drinks □ □ □ Certain foods □ □ □

Cold drinks □ □ □ Certain drinks □ □ □

 Chewing Gum □ □ □ Certain smells □ □ □

Sour lollies □ □ □ Body odour □ □ □

Crunchy Food □ □ □ Body wash/soaps □ □ □

Bland food □ □ □ Candles/Oils □ □ □

Other things that may be helpful, such as places, or things that a family member or friend could do or bring to
help you feel calm and/or safe:
 Sensory Safety Plan
This sensory Safety Plan helps to identify ways for you to calm emotions and manage stressful situations by
increasing understanding of:
 Your early warning signs
 Your unique sensory preferences and sensory based activities which are helpful for coping
Warning Signs:
What you might notice:

What others might notice:

Triggers:

Sensory Strategies
What is helpful:

What is not helpful:

What others can do:

Places I feel safe:

Other: