Copyable domestic violence safety plan template for clinical use
A domestic violence safety plan helps a client think through safer options before, during, or after an abusive incident. For therapists, counselors, social workers, psychologists, and other behavioral health clinicians, the plan can also create a clear structure for documenting risk, protective factors, client choices, and follow-up needs.
This template is designed for clinical conversations, not as a one-size-fits-all instruction sheet. Review each section with the client, adapt it to their situation, and avoid sending or printing anything that could increase risk if found by an abusive partner, family member, or household member.
If a client is in immediate danger, prioritize emergency support according to your clinical setting, local procedures, and applicable reporting requirements. A written plan should never delay urgent safety action.
DOMESTIC VIOLENCE SAFETY PLAN TEMPLATE Client name or identifier: Date completed: Clinician: Preferred safe method of contact: Do not contact by: 1. Current safety concerns What has been happening recently? Known triggers or escalation patterns: Recent threats, stalking, weapons, strangulation, forced sex, or severe injury: Children, pets, elders, or other dependents affected: Substance use, mental health crisis, or other factors increasing risk: 2. Warning signs that danger may be increasing The client notices: The abusive person may: Environmental signs: Other concerns: 3. Safer places the client can go Primary safe place: Backup safe place: Public place nearby: Shelter, advocacy program, or community resource: Transportation options: 4. People who may be able to help Trusted person #1: Phone/contact method: Code word or phrase: What this person can do: Trusted person #2: Phone/contact method: Code word or phrase: What this person can do: 5. Leaving or getting away Possible exit routes: Best time or situation to leave, if applicable: Where keys, wallet, documents, medication, and phone may be kept: Plan for children, pets, or dependents: Transportation plan: 6. Items to consider keeping accessible Identification: Cash, bank card, or financial information: Medication and medical items: Phone charger: Legal, immigration, school, or custody documents: Clothing, comfort items, or children’s items: 7. Technology and privacy considerations Safer phone or device: Accounts that may need password review: Location sharing concerns: Social media or email concerns: Safe place to store this plan: 8. Emotional safety and coping Grounding skills that help: People the client can contact for emotional support: Places the client feels calmer: Steps after an incident: 9. Legal, medical, and advocacy resources Emergency contact: Domestic violence advocate or program: Medical care option: Legal resource: Other community resource: 10. Clinician follow-up Client’s stated next step: Referrals offered: Client accepted or declined referrals: Risk level and clinical rationale: Plan for next session or check-in: Documentation considerations:
How to use this safety plan in session
Start with the client’s priorities. Some clients want help leaving. Others are not ready to leave, cannot safely leave, or are trying to reduce harm while they assess options. A useful plan respects the client’s autonomy while documenting your clinical assessment and support.
Move slowly through sensitive sections. Questions about weapons, strangulation, stalking, forced sex, immigration status, finances, and children can affect risk and may require careful pacing. Ask permission before taking notes in detail, especially if the client has privacy concerns about portals, printed documents, shared devices, or insurance records.
- Use the client’s words when documenting their stated concerns, goals, and preferred next steps.
- Separate clinical assessment from instructions so the note is clear about what was discussed versus what the client chose.
- Document referrals offered without implying that the client was required to accept them.
- Review the plan regularly because risk, housing, phone access, finances, and support people can change quickly.
Some clinicians keep the written plan brief and document more detail in the clinical note. Others help the client create a separate personal plan that is stored outside the chart. The right approach depends on the client’s safety, your setting, and your documentation policies.
Completed domestic violence safety plan sample
The example below is fictional. It shows the level of detail a clinician might use after a safety planning session while still keeping the client in control of decisions.
DOMESTIC VIOLENCE SAFETY PLAN SAMPLE Client name or identifier: M.R. Date completed: 06/18/2026 Clinician: J. Lee, LCSW Preferred safe method of contact: Client will call clinic directly. Do not contact by: Text message or email unless client requests it. 1. Current safety concerns Client reports partner has been yelling, blocking exits, checking phone, and threatening to take the car keys. Client reports one incident of being pushed last month. Client denied current injuries today. Client stated fear increases when partner drinks heavily and when client discusses ending the relationship. 2. Warning signs that danger may be increasing Client notices partner pacing, raising voice, standing near the door, and taking client’s phone. Client identified weekend evenings as higher-risk times. Client stated partner has recently increased monitoring of client’s location. 3. Safer places the client can go Primary safe place: Cousin’s apartment, approximately 20 minutes away. Backup safe place: 24-hour grocery store near client’s workplace. Public place nearby: Gas station on Main Street. Shelter or advocacy program: Client accepted information for local domestic violence advocacy agency. Transportation options: Client may use own car if keys are available; backup plan is rideshare from workplace or cousin pickup. 4. People who may be able to help Trusted person #1: Cousin A. Code word: “Can you bring the blue folder?” What this person can do: Pick client up, provide temporary place to stay, hold copies of documents. Trusted person #2: Coworker B. Code word: “I need the schedule changed.” What this person can do: Stay with client at work, help call cousin, call emergency services if client requests or appears in immediate danger. 5. Leaving or getting away Client identified front door and kitchen door as exits. Client plans to keep keys, wallet, medication, and phone charger in work bag when safe to do so. Client stated that if partner blocks exits or threatens harm, client will attempt to move toward a public area and call emergency services if able. 6. Items to consider keeping accessible Client plans to ask cousin to hold copies of ID, insurance card, child’s birth certificate, and extra medication. Client does not plan to pack a visible bag at home because partner may notice. 7. Technology and privacy considerations Client believes partner may know phone passcode. Client plans to change passcode from a safer device and review location sharing when away from home. Client does not want safety plan sent through portal. 8. Emotional safety and coping Client identified paced breathing, calling cousin, sitting in car at workplace, and grounding with cold water as helpful. Client stated shame and fear of judgment make it harder to ask for help. Clinician validated concerns and reinforced that client can choose next steps. 9. Legal, medical, and advocacy resources Client accepted domestic violence advocacy resource information verbally and wrote it in personal notebook. Client declined legal referral today but agreed to revisit next session. Client was encouraged to seek medical care if injured. 10. Clinician follow-up Client’s stated next step: Talk with cousin this week and arrange document copies. Referrals offered: Domestic violence advocacy agency, emergency services if immediate danger, medical care if injury occurs. Client accepted or declined referrals: Accepted advocacy information; declined legal referral today. Risk level and clinical rationale: Elevated safety concern due to recent physical aggression, monitoring, threats involving transportation, and client fear. Client denied immediate danger during session and identified safe contacts. Plan for next session or check-in: Review contact with cousin, technology privacy, and updated risk. Continue trauma-informed support and safety planning.
When clinicians may use a domestic violence safety plan
Safety planning may be appropriate when a client describes current or past intimate partner violence, family violence, coercive control, stalking, threats, sexual violence, or fear of retaliation. It can also be useful when a client is preparing for a breakup, custody exchange, move, court date, or other event that may increase danger.
Use clinical judgment before introducing the template. A client who is being monitored may not be able to safely take a printed plan home. A client in crisis may need immediate support before completing a structured form. A client who feels overwhelmed may benefit from one practical step rather than a full written plan.
- Intake sessions: Use brief screening responses to guide safety questions and referrals.
- Ongoing therapy: Revisit the plan when risk changes or the client identifies new concerns.
- Crisis sessions: Focus on immediate safety, safe contacts, and next steps.
- Care coordination: Document referrals to advocacy, medical, legal, or community supports when appropriate.
The plan can support trauma-informed care because it emphasizes choice, pacing, collaboration, and practical safety needs. It should not pressure the client to leave, report, file charges, or disclose more than they are ready to share.
Key sections to include in the clinical note
The client-facing plan and the clinical note do not have to be identical. Your progress note should capture clinically relevant information while avoiding unnecessary detail that could create risk if accessed by someone else. Follow your practice policies, applicable laws, and professional standards.
A strong note usually includes the presenting concern, risk factors discussed, protective factors, interventions used, client response, referrals offered, and follow-up plan. If you use SOAP, DAP, BIRP, GIRP, or another format, place the safety planning details where they fit naturally.
Example documentation language
SOAP-style wording: Client reported increased fear related to partner’s monitoring of phone, verbal threats, and recent physical aggression. Clinician assessed current safety, explored escalation patterns, and collaborated with client on safer contacts, transportation options, and privacy considerations. Client identified cousin as primary support and declined legal referral today. Plan is to review safety concerns next session and update plan as needed.
DAP-style wording: Client described feeling “trapped” and worried that partner may take keys during arguments. Clinician provided supportive counseling, assessed immediate danger, and completed collaborative safety planning focused on safe contacts, exit options, and technology privacy. Client appeared anxious but engaged and identified one concrete step: asking cousin to hold copies of documents. Continue monitoring risk and support client-directed planning.
Common mistakes that can weaken a safety plan
Domestic violence safety planning requires more than filling in blanks. The most common problems happen when the plan is too generic, too visible, or disconnected from the client’s real choices and risks.
- Assuming leaving is the only goal: Leaving can be complex and may increase danger for some clients. Plan around the client’s stated priorities.
- Creating a plan the abusive person could find: Discuss safe storage, device privacy, portal access, and printed copies before sharing anything.
- Skipping technology safety: Phones, shared accounts, location tracking, vehicle apps, and social media can affect the client’s options.
- Using vague documentation: Phrases like “safety discussed” may not show the clinical reasoning, interventions, or follow-up plan.
Another mistake is over-documenting details that are not needed for care. For example, writing the exact address of a safe house may be unnecessary and could create risk. Instead, the note might state that the client identified a safe family member’s home and discussed transportation options.
Review the plan after major changes: separation, reconciliation, pregnancy, job loss, court involvement, new housing, new phone access, or threats involving children or pets. A plan that was useful three months ago may not match the client’s current situation.
Domestic violence safety planning checklist
Use this quick checklist after the session to see whether the plan and note cover the core clinical areas.
- Current safety concerns, escalation patterns, and immediate risk were assessed.
- Client identified safer places, safe contacts, and a preferred contact method.
- Technology privacy, transportation, important items, and dependents were considered.
- Referrals, client choices, clinical interventions, and follow-up plan were documented.
If any item is missing, decide whether it needs to be addressed now, at the next session, or through a referral. The checklist is a guide, not a substitute for clinical judgment.
How AutoNotes helps document safety planning sessions faster
Domestic violence sessions can involve risk assessment, trauma responses, resource discussion, care coordination, and detailed follow-up. Writing that note after a full day of sessions can be difficult, especially when the documentation needs to be clear and clinically precise.
AutoNotes helps behavioral health professionals create structured, editable progress note drafts from session details. Instead of starting with a blank page, you can generate a draft that organizes safety concerns, interventions, client response, referrals, and next steps in a clinical format such as SOAP, DAP, BIRP, GIRP, or other documentation styles.
The clinician remains responsible for reviewing, editing, and finalizing every note. That matters in safety planning. AI can help organize the draft, but it should not decide risk level, replace clinical judgment, or determine what details are safe to include in the record.
- Service-specific templates help match the note to the session type, such as intake, crisis support, individual therapy, or treatment planning.
- Editable drafts let clinicians revise wording, remove sensitive details, and add clinical rationale before finalizing.
- Consistent structure supports clearer documentation across risk assessment, interventions, response, and plan.
- Faster drafting can reduce after-hours note writing while keeping the provider in control.
If domestic violence safety planning is part of your clinical work, AutoNotes can give you a faster starting point for documenting these complex sessions. Start your free trial to try editable AI-assisted note drafts built for behavioral health documentation.
Quick answers for clinicians using this template
Should every client experiencing domestic violence receive a written safety plan?
Not always. A written plan may be unsafe if the abusive person monitors the client’s belongings, phone, email, or portal. In those cases, verbal planning, coded notes, or a plan stored with a trusted person may be safer.
Can this template be used for telehealth?
Yes, but confirm privacy first. Ask whether the client is alone, whether anyone can overhear, and whether it is safe to discuss domestic violence. Use neutral language if privacy is uncertain.
How detailed should the progress note be?
Document enough to support clinical care, risk assessment, interventions, referrals, and follow-up. Avoid unnecessary details that could increase risk, such as exact safe locations, unless there is a clear clinical reason to include them.
How often should the plan be updated?
Update it whenever risk, housing, relationship status, technology access, transportation, custody issues, or support people change. For higher-risk situations, review it more frequently.
Can AutoNotes create the safety plan itself?
AutoNotes can help draft structured clinical documentation from the details you provide. The clinician should still complete the safety planning conversation, assess risk, edit the draft, and finalize the note based on clinical judgment.
