Home and Community Based Services Waiver
Safety Alert Plan
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Identified Client Name and ID #: | DOB: |
Individualized Care Coordinator:
ICC Agency Phone Number: |
Date Completed: |
Caregiver/Parent's Name:
Caregiver/Parent's Phone Number: |
|
Address:
Directions to home: |
|
Names, relationships and phone numbers of persons helpful in assisting the child with interventions: | |
School Name, address, contact person and phone number (if involved in the Safety Alert Plan): |
Early Warning Signs that the Youth is Becoming Upset
Restlessness
Sweating
Shortness of Breath
Pacing
Not talking
Not making eye contact
Crying/teary eyed
Clenching teeth
Rapid speech
Tangential thought process
Not taking medication
Repetitive, ritualistic behaviors
Behaviors of Concern
Current behaviors (within the last 90 days and where they happen):
Fighting
Self harm
Explain:
Suicide attempt
When & how:
Suicidal ideation
Running away
Gang involvement
Biting
Hitting
Cruelty to animals
Hallucinations
Explain:
Stealing
Illicit drug use
Explain:
Not following directions
Fire setting
Inappropriate sexual
behavior- explain:
Other specific behaviors (describe):
Where do behaviors of concern most often occur?
Intervention Strategies (what works?) and Child/Family Strengths
Exercise
Change of environment
Listening to music
Reading
Take a walk
Ripping paper
Writing about feelings
Drawing
Watching television
Playing games
Leaving the situation
Counting to ten
Time alone
Talking to someone (who?)
Punching a pillow
Other specific interventions (describe):
Other actions to be taken by family members present:
Current Diagnosis, Medical Concerns and Risk History
Diagnosis:
Presentation of diagnosis:
Medical conditions:
All current medications:
Dates of hospitalizations/ER visits (psychiatric and physical) within the past year:
History of risk behaviors (and time frames):
Required Signatures (for initial safety plan and for each updated safety plan)
Child:
Parent/Caregiver:
ICC Supervisor:
If school provides identified safety interventions:
School Contact Signature:
Date:
Date:
Date:
Date:
Date Copy of initial Safety Alert Plan and Updates Given to Family:
Date Copy of Initial Safety Alert Plan and Updates Given to School (if required):
Rev.5/10