Safety Plan
Building Respectful Family Relationships
I agree to the following plan to prevent abuse or violence:
1. I will separate from my family member/s when
- I start to feel angry or upset and might become hurtful
- I start to use any hurtful behaviors including the following:
Yelling
Name-calling/profanity
Threats
Intimidating behaviors
Property damage
Unwanted physical contact, such as,
hitting, punching, pushing, kicking,
slapping, grabbing, or other
unwanted contact
2. I will tell the person I am separating by saying:
_____________________________________________________
3. I will separate from the person and go to one of the following places:
______________________________________________________
4. While I am separated I will do something to calm myself down, such as:
_______________________________________________________
5. I will stay away from others for 15 – 20 minutes, or until I can be safe and respectful to everyone in the house.
I agree to the following rules:
- I will not use this to plan as an excuse to leave the house or do things I am not supposed to do.
- After my separation time I will return and make a plan with the other person about what to do next, (i.e., finish the discussion, plan a time later to talk about it, or let it go).
- If the other person separates from me I will respect their time alone and not bother them.
- I will stay away from the other person until they are ready to talk again.
I agree to follow this plan to help me stay safe and respectful.
___________________________________________________________
Youth Signature
Date: _______________
Parent Agreement:
I also agree to be non-violent and to support my youth in following this plan.
____________________________________________________________
Parent Signature
Date: _______________