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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

Home and Community Based Services Waiver
Safety Alert Plan

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Identified Client Name and ID #: DOB:
Individualized Care Coordinator:

ICC Agency Phone Number:

Date Completed:
Caregiver/Parent's Name:

Caregiver/Parent's Phone Number:

Address:

Directions to home:

Names, relationships and phone numbers of persons helpful in assisting the child with interventions:
School Name, address, contact person and phone number (if involved in the Safety Alert Plan):

Early Warning Signs that the Youth is Becoming Upset

check box Agitation
check box Restlessness
check box Sweating
check box Shortness of Breath
check box Pacing
check box Isolating/Withdrawing
check box Not talking
check box Not making eye contact
check box Crying/teary eyed
check box Clenching teeth
check box Verbal defiance
check box Rapid speech
check box Tangential thought process
check box Not taking medication
check box Repetitive, ritualistic behaviors
Other early warning signs (describe):

Behaviors of Concern
Current behaviors (within the last 90 days and where they happen):

check box Cursing
check box Fighting
check box Self harm
Explain:
check box Suicide attempt
When & how:
check box Suicidal ideation
check box Destroying property
check box Running away
check box Gang involvement
check box Biting
check box Hitting
check box Cruelty to animals
check box Hallucinations
Explain:
check box Verbal aggression
check box Stealing
check box Illicit drug use
Explain:
check box Not following directions
check box Fire setting
check box Inappropriate sexual
behavior- explain:

Other specific behaviors (describe):

Where do behaviors of concern most often occur?

Intervention Strategies (what works?) and Child/Family Strengths

check box Positive reinforcement
check box Exercise
check box Change of environment
check box Listening to music
check box Reading
check box Take a walk
check box Ripping paper
check box Talking about feelings
check box Writing about feelings
check box Drawing
check box Watching television
check box Playing games
check box Leaving the situation
check box Taking deep breaths
check box Counting to ten
check box Time alone
check box Talking to someone (who?)
check box Punching a pillow

Other specific interventions (describe):

Other actions to be taken by family members present:

Current Diagnosis, Medical Concerns and Risk History

Diagnosis:
Presentation of diagnosis:
Medical conditions:
All current medications:
Dates of hospitalizations/ER visits (psychiatric and physical) within the past year:
History of risk behaviors (and time frames):

Required Signatures (for initial safety plan and for each updated safety plan)

ICC:

Child:

Parent/Caregiver:

ICC Supervisor:

If school provides identified safety interventions:

School Contact Signature:

Date:

Date:

Date:

Date:

Date:

 

Date Copy of initial Safety Alert Plan and Updates Given to Family:

Date Copy of Initial Safety Alert Plan and Updates Given to School (if required):

Rev.5/10

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.