Project for Pride in Living

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 during a violent incident.

 I can keep my purse and car keys ready and put them _________________ in order to leave quickly.

 If I have to leave my home, I will go to ________________________. (Decide this even if you don't
think there will be a next time.) If I cannot go there, I will go to ______________________.

 When I expect we are going to have an argument, I will try to move to a space that is lowest risk, such
as _______________________. (Try to avoid arguments in the bathroom, garage, kitchen, near
weapons, or in rooms without access to an outside door.)

Step 2: Safety when preparing to leave.

 I will leave money and an extra set of keys with ____________________ and important documents
at/with __________________ so I can leave quickly.

 ______________ is someone I trust, who can give me the support I need when preparing to leave.

In case you have to leave, have the following available:

 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)

Step 3: Safety in my residence/shelter.

 I can 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 ____________________

 I will tell my ________________ (counselor, advocate, etc.) about my partner and seek support.

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

Step 4: Legal safety.

  If I have a protection order, I will keep a copy ____________________ (where) 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 will inform my advocate _________________ and employer _____________________ that I have a

protection order in effect.

 If I feel threatened I can go into a store, gas station, restaurant to call __________________ for help.

 I will contact my bank about protecting any accounts that may be accessed.

Step 5: 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:
a. School_____________________________________
b. Day Care___________________________________
c. Babysitter__________________________________
d. Teacher____________________________________
e. 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 6: Drug and Alcohol Use

 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 for my child/ren . . .
____________________________________________________________________________________
____________________________________________________________________________________

 To protect my children, I can

____________________________________________________________________________________
____________________________________________________________________________________

 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 7: 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 to provide my children with the best
care and services necessary in all instances.

 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.

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

I understand that the Minnesota Data Privacy Act may protect my records. Any information received by
Project for Pride in Living shall remain confidential. I understand that I have the right to refuse to supply the
information requested, however, without this information, Project for Pride in Living may not be able to
provide me with the services I am requesting. I understand that I may revoke this consent at any time by
written notice. Without a written notice to revoke this consent (unless information has already been released)
this authorization will expire after 12 months from the date of my signature.

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.

 ___________________________________________________ ______________________________
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).