Personal Safety Plan for Victims of Domestic Violence and Abuse

[Rev. Dr. Dorothy E. Hooks, PsyD]

The Lula McGrady Foundation, Inc.                                                                                  

P.O. Box 490562                        

Leesburg, FL 34749-0562     

352.406.2209 - Office

[e-mail] – Email

 www.lulamcgrady.org - Web site                                      

 

 

                          

Personal Safety Plan

 

Please answer the questions below to develop your own safety plan. Let us know if you would like a copy of your plan.

 

 Client Name:_________________________________________________ Date:_______________________________

 

 1. If I decide to leave, I will________________________________________________.

 

2. I can keep a bag ready and put it______________________ so I can leave quickly.

3. I can tell________________________________about the violence for them call the police when

    violence erupts.

 

4. I will leave money and an extra set of keys with___________________________________________.

5. I will keep important documents and keys at___________________________________________________.

6. The domestic violence hotline is _____________________.

7. The shelter's hotline is _________________________.

8. I will rehearse the escape plan and practice it with my children.

9. I can change the locks on my doors and windows as soon as possible.

10. I will teach my children how to use the phone to make collect calls to me and to  

         ___________________________ (friend, family, minister) if my partner tried to take them.

11. I will tell the people who care for my children, who have permission to pick them

      up.  My  partner is NOT allowed to pick them up. Inform the following people:

 

      School_________________________________________________________ 

      DayCare_______________________________________________________

      Babysitter_____________________________________________________

      Teacher_______________________________________________________

                                                                                                                                 

 12. I can tell my the following people that my partner no longer lives with me and that

       they  should call  the police if he is near my residence:

 

 

      Neighbors__________________________________________________

      Friends_____________________________________________________

 

13. I can call the local domestic violence agency if I am not sure how to register my

       protection order with the police departments.

 

14. If my protection order gets destroyed, I know I can go to the County Courthouse and

       get another copy.

 

15. I can tell my boss, security, and ____________________________ at work about this situation.

 

16. I can ask___________________________________ to help screen my phone calls.

 

17. When leaving work I can do the following:    

 

__________________________________________________________________________

__________________________________________________________________________

 

18. When I am driving home from work and problems arise, I

 

can_____________________________________________________________________

        ___________________________________________________________________

         ___________________________________________________________________

 

19. If I use public transportation, I can________________________________________

       ____________________________________________________________________

       ____________________________________________________________________

 

20. If I feel depressed and ready to return to a potentially violent situation/ partner, I can call__________________________________________________________________________

 

 

Client Signature:______________________________________________ Date:____________________________

 

Jesus loves YOU! You are not alone!