Homelessness Safety Plan Form
Use this form to develop a practical safety plan tailored to your current situation and needs.
Preferred Name
Current Contact Method
*
Please Select
Cell phone (call/text)
Email
Through outreach worker
No current contact method
Other
Current Location or Usual Areas
*
Immediate Safety Concerns
*
Safe Places to Go (if needed)
*
Emergency Contact Name and Method
*
Preferred Support Services
Shelter/Housing
Food Assistance
Mental Health Support
Medical Care
Substance Use Support
Employment/Income Support
Legal Assistance
Other
Mobility or Transportation Needs
No transportation needed
Bus pass needed
Rideshare or taxi needed
Assistance with mobility devices
Other
Medical or Accessibility Needs (relevant to safety planning)
Additional Notes or Information
Submit Safety Plan
Should be Empty: