Emergency Contact & Safety Plan template

1. Purpose

• This form records who my provider may contact in an emergency, and my agreed safety plan, so that appropriate support can be arranged quickly if needed.

2. Consent to Contact in an Emergency

• I consent to my provider contacting the person(s) named below, my GP, or emergency services if there is a serious concern about my safety or the safety of others, even without my prior agreement at that moment.

3. Safety Plan

• Key Coping Strategies / Support ContactsText

• My provider and I have discussed warning signs, coping strategies, and support contacts to use if I feel unsafe. This plan will be reviewed and updated together as needed.

4. Data Protection

• This information is processed under the UK GDPR and Data Protection Act 2018 and is shared only as necessary to keep me safe.

Client Information

• Full NameText
• GP Name / SurgeryText

Practitioner Information

• Practitioner NameText
• Registration No.Text

Emergency Contacts

• Primary Contact Name / RelationshipText
• Primary Contact PhoneText
• Secondary Contact Name / RelationshipText
• Secondary Contact PhoneText

Acknowledgment and Signature

• Client SignatureSignature
• Date signed (client)Date
• Practitioner SignatureSignature
• Date signed (practitioner)Date

• By signing below, I consent to the emergency contact and safety plan arrangements described above.