D.15 b. SUICIDE PREVENTION SAFETY PLAN - ATTACHED.pdf

SUICIDE PREVENTION SAFETY PLAN

If the Veteran declines to complete the Safety Plan OR if you are reviewing an existing Safety Plan with the Veteran and no changes are needed, please complete the ***Suicide Prevention Safety Plan

Review/Decline*** note to document the review or decline.

If creating a new Safety Plan, or if, upon review, changes need to be made to an existing Safety Plan, continue with this note, completing ALL fields and incorporating changes.

The Safety Plan is a pre-determined written list of coping strategies and sources of support that

Veterans who are at risk for suicide can use before or during a crisis. The rationale for using a Safety

Plan is to help Veterans recognize when they are experiencing a crisis and to use specific strategies to avert a crisis and prevent them from acting on their suicidal thoughts and urges. The Safety Plan serves as an emergency plan to use during crises when problem solving abilities often diminish.

The Safety Plan is a brief, easy-to-read document that uses the Veteran’s own words. To foster collaboration, it is best to complete a paper and pen version of the plan with the Veteran prior to entering it into the EHR. The template allows for a limited number of characters per line and a limited number of lines. Once you click ‘finish,’ however, you can add beyond those character and line limits for cases where the Veteran has developed a particularly robust and detailed Safety Plan. Veterans must be given a hard copy of the Safety Plan as it may serve as a reminder to engage in strategies to reduce risk. Many Veterans may also choose to enter much of the safety plan information into a related smartphone app, such as MY3 or Virtual Hope Box.

Before introducing the Safety Plan template or form, it is recommended that the clinician ask the

Veteran to briefly describe his or her crisis that was associated with an increased risk for suicide. For example, the clinician may ask, “Would you tell me what happened when you experienced a crisis and were in danger of acting on your suicidal feelings?” Offer empathy and support when asking about the crisis. From the Veteran’s description, it is helpful for the Veteran to identify the warning signs associated with the beginning of the crisis and to observe how suicidal thoughts come and go as the crisis diminishes. The rationale for obtaining this information is for the Veteran to see how it may be possible to avert or de-escalate a crisis by recognizing when a crisis begins or worsens and then using coping strategies and other sources of support in a step-by-step way. Explain that suicidal feelings do not last indefinitely and that having strategies to cope in place beforehand can help manage a suicidal crisis and allow the crisis to pass without engaging in suicidal behavior.

Inform the Veteran that once the Veteran recognizes the warning signs, then he or she should follow the steps described on the Safety Plan. If following the coping strategies described for one step is unhelpful for de-escalating the crisis, then encourage the Veteran to go to the next step on the Safety

Plan and continue to follow the steps until the crisis is diminishes and the risk for suicide is lower.

However, also inform the Veteran that it is not necessary to follow this list of strategies before reaching out for help.

After the Safety Plan is developed, review the entire Safety Plan with the Veteran, assess the likelihood that the Safety Plan will be used, and problem-solve with the Veteran any barriers to using the plan. Discuss where the Veteran will keep the Safety Plan, specifically. Evaluate whether the content and format is appropriate and feasible for the Veteran’s capacity and circumstances.

D.15 b) SUICIDE PREVENTION SAFETY PLAN D.15 b) SUICIDE PREVENTION SAFETY PLAN - 36C26225R0004

Reviewing the Safety Plan

Review the Safety Plan periodically with the Veteran and family members (if appropriate) when the

Veteran’s circumstances or needs change. The clinician may ask,

(1) Do you remember the last Safety Plan you developed?

(2) Have you actually used the Safety Plan?

(3) If so, was the Safety Plan helpful for preventing you from acting on your suicidal thoughts and urges? If not, why not?

(4) How can the Safety Plan be revised so that it can be more helpful to you?

Collaboratively Completing Specific Steps of the Safety Plan

When completing each of the following 6 steps of the Safety Plan, the clinician collaboratively works with the Veteran to: (1) understand the reasons for each step, (2) brainstorm ideas, by asking the

Veteran for suggestions or offering choices, to identify specific warning signs, coping strategies, or resources, and (3) ask for feedback to improve feasibility and remove barriers for each response. The

Safety Plan is not simply a form to be filled out without involvement of the clinician.

Time Requirement for Safety Planning

The time required for safety planning varies, but it is not meant to be a quick process. It generally takes 20-30 minutes or longer to complete a new Safety Plan; updating a Safety Plan may take less time but should still be thorough.

Safety Planning Resources:

• For VA educational materials for safety planning including the updated safety planning manual, educational videos, and other resources, visit https://dvagov.sharepoint.com/sites/VACOMentalHealth/SitePages/Safety-Planning-%26-Suicidal-

Behavior-Reporting.aspx for more information.

• For additional support in safety planning (including lethal means safety counseling), please contact the VA Suicide Risk Management Consultation Program (email srmconsult@va.gov or visit https://www.mirecc.va.gov/visn19/consult/index.asp for more information).

TIP: Filling out the note template

• You will not be able to click “finish” until boxes have been clicked and content is written in required sections. If you need information elsewhere in the chart to complete a required section you can type a few characters, such as x’s or 1’s, as place holders so you can search for the information you need and eventually complete the note and sign it.

• The template only allows a few entries per section and so many characters per entry. Some

Veterans can create a robust safety plan with many more interventions per section. You can add those interventions AFTER you have clicked FINISH and turned the template into a normal note.

Remind the Veteran:

Please follow the steps described below on your safety plan. If you are experiencing a medical or mental health emergency, please call 911, at any time. If you are unable to reach your safety contacts or you are in crisis, please call the Veterans Crisis Line at 988 (press 1) or 1-800-273-8255 (press 1).

D.15 b) SUICIDE PREVENTION SAFETY PLAN - 36C26225R0004 https://dvagov.sharepoint.com/sites/VACOMentalHealth/SitePages/Safety-Planning-%26-Suicidal-Behavior-Reporting.aspx https://dvagov.sharepoint.com/sites/VACOMentalHealth/SitePages/Safety-Planning-%26-Suicidal-Behavior-Reporting.aspx mailto:srmconsult@va.gov https://www.mirecc.va.gov/visn19/consult/index.asp

Step 1: Triggers, Risk Factors and Warning Signs

Purpose: Explain to the Veteran that it is important to identify and recognize specific warning signs when a crisis is occurring or escalating to remind the Veteran to use the Safety Plan. Identify specific thoughts, images, emotions, physical sensations, or behaviors that occur during crises and record them using the Veterans own words. If the Veteran has described the suicidal crisis, you will already have a sense of the warning signs. If the Veteran is struggling to identify warning signs, you can help by making suggestions derived from the crisis narrative.

Note that triggers describe external life events that occur that may be associated with a crisis and warning signs generally indicate how the Veteran is reacting to these events. Risk factors are those clinical characteristics or experiences associated with imminent suicide risk.

TIP: Given that warning signs serve as a reminder to use the Safety Plan, it is important that they are specific and not vague signs. Examples of vague signs are “thinking about the future,” feeling upset, feeling out of it, and arguing. Work with the Veteran to identify vague signs and make them more specific.

TIP: It is better to identify warning signs that are internal rather than external events. For example, if the Veteran identifies a financial set back as a warning sign, ask, “What could be your reaction to this set back that indicates that you are experiencing a crisis?”

Ask: – How will you know when you are in crisis and that the safety plan should be used?

What are your personal red flags?

Specific examples of warning signs:

• Thoughts: “I feel worthless.” “I feel like a burden to my family.” “It’s hopeless; things won’t change or get better.” “There is no way out other than to kill myself.”

• Having racing thoughts, thinking about many problems with no conclusions (feeling overwhelmed).

• Intense Emotions: Feeling very depressed, anxious, angry, shame.

• Physical Sensations: not sleeping, loss of appetite,

• Behavior: Isolating self, pacing, giving things away, crying a lot, drinking more than usual

1._______________________________________________________________________________

2._______________________________________________________________________________

3._______________________________________________________________________________

4._______________________________________________________________________________

5._______________________________________________________________________________

Review: After warning signs have been identified, remind the Veteran that the presence of warning signs is an indication that the safety plan should be put into action. Explain that the plan should ordinarily be used in a stepwise fashion unless the Veteran needs emergency rescue.

Step 2: Internal Coping Strategies

Purpose: Explain to the Veteran that the purpose of internal coping strategies is to help take the individual’s mind off one’s problems to prevent escalation of suicidal thoughts and prevent making a suicide attempt. The clinician should ask Veterans to identify specific behavioral activities that can serve as strong distractors to suicidal thinking without contacting another person. The warning signs identified in Step 1 do not have to be addressed, specifically, during this step. Engaging in problem solving or responding to specific thoughts is often challenging to do during a crisis. The best strategies here are simple, easy to use and absorbing.

TIP: Activities that are vague are less likely to be used or helpful than specific ones. For example, “watching a (specific) comedy show is better than watching television.” Identifying activities that are meaningful, enjoyable, soothing or offer hope are helpful as long as they serve as effective distractors from one’s problems.

TIP: Do not endorse distracting activities that are likely to increase suicide risk such as “having a few drinks,” “sharpening knives,” “cleaning my firearms,” etc.

TIP: Consider sharing information or working with the Veteran to create a Virtual Hope Box as a coping strategy. You can find more information about Virtual Hope Box and how to install it on a smartphone here: https://health.mil/Reference-Center/Fact-Sheets/2022/01/19/Virtual-Hope-Box-App

Ask: – What can you do, on your own, to help you to stay safe and not act on your suicidal thoughts or urges in the future?

What have you done in the past to stay safe?

1._____________________________________________________________________

2._____________________________________________________________________

3._____________________________________________________________________

4._____________________________________________________________________

5._____________________________________________________________________

Review: Assess the likelihood of using internal coping strategies and explore potential barriers for each response listed on the Safety Plan. Ask “How likely do you think you would be able to do this strategy during a time of crisis?” If doubt about use is expressed, ask, “What might stand in the way of you thinking of each of these activities or doing them if you think of them?” Use a collaborative, problem solving approach to address potential roadblocks and identify alternative coping strategies.

https://health.mil/Reference-Center/Fact-Sheets/2022/01/19/Virtual-Hope-Box-App

Step 3: Social Contacts Who May Distract from the Crisis

Purpose: Encourage engagement with people and social settings that provide distraction. Clinicians and formal health or mental health care providers should not be included in this Step. Remind the

Veteran to use Step 3 if Step 2 does not resolve the crisis or lower risk.

If the Veteran does not want to reveal social contacts, it is okay to leave this section blank after discussion, but in such cases, the clinician must select the items at the bottom of this section, stating that the Veteran describes a lack of social contacts. Otherwise, this section will be considered incomplete.

The Veteran can also use a nickname or first name only for the contact if he/she does not want to provide full names. Phone numbers for contacts should be listed on the Safety Plan, even if the

Veteran already has those numbers memorized or stored elsewhere.

Ask – Other than mental health providers and counselors, who can you contact who helps take your mind off your problems or helps you feel better?

Name: ______________________________ Phone number: _____________________

Name: ______________________________ Phone number: _____________________

Name: ______________________________ Phone number: _____________________

Name: ______________________________ Phone number: _____________________

Name: ______________________________ Phone number: _____________________

Name: ______________________________ Phone number: _____________________

□ Veteran describes a lack of social contacts

Ask – What public places, groups, or social events help you take your mind off your problems or help you feel better?

Examples of social settings include community events, beaches, parks, coffee shops, malls, churches, clubs, 12 step-meetings, aftercare groups, support groups, Veterans organizations, Vet

Center social events.

TIP: Specific places should be identified rather than vague places. Be sure that the identified person or place does not increase suicide risk, such as going to the bar. Also, places that are readily accessible and frequently available are best. Social activities that require advanced planning are not typically helpful here.

1._____________________________________________________________________

2._____________________________________________________________________

3._____________________________________________________________________

4._____________________________________________________________________

5._____________________________________________________________________

6. _____________________________________________________________________

Review: Assess likelihood that the Veteran will contact others or visit places or events listed during a crisis; identify potential barriers and resolve them. Ensure that listed places are ones that the Veteran would be willing to visit and believes they are likely to visit. Do not list places or events (such as AA meetings, church services, Vet Center events) that Veteran has never visited in the past and that

Veteran may have no real intent to visit but “sounds good” to the clinician.

Step 4: Family Members or Friends Who May Offer Help

Purpose: Explain to the Veteran that next step on the Safety Plan involving telling a family member or friend that he/she is in crisis and needs support. Instruct the Veteran to use Step 4 if Step 3 does not resolve the crisis or lower risk. Help the Veteran distinguish between individuals who are distractors (Step 3) and individuals who can help resolve the crisis.

If the Veteran does not want to reveal his/her distress to family members, it is okay to leave this section blank after discussion, but you must select one or both items at the bottom of this section, stating that:

- Veteran describes a lack of family or friends

OR

- Veteran chooses not to disclose distress to friends or family.

Otherwise, this section will be considered incomplete.

As with Step 3, nicknames or first names can be provided, but phone numbers should be included.

TIP: This step is an opportunity to encourage Veteran to share their completed Safety Plan with trusted family and friends if they are so willing. The Veteran may ask family members or friends to use or follow the Safety Plan if they observe that the Veteran is in crisis.

TIP: If the Veteran discloses having no friend/family support, then consider interventions to address social isolation or social skills, such as social skills training, peer support, intensive referral to mutual help, group therapy, behavioral activation, etc.

Ask – Who are friends or family members who should be included in your plan?

Name: ______________________________ Phone number: _____________________

Name: ______________________________ Phone number: _____________________

Name: ______________________________ Phone number: _____________________

Name: ______________________________ Phone number: _____________________

Name: ______________________________ Phone number: _____________________

Name: ______________________________ Phone number: _____________________

□ Veteran describes a lack of family or friends

□ Veteran chooses not to disclose distress to friends or family.

Review: Assess likelihood individual will engage in this step; identify potential obstacles, and problem solve. If the Veteran expresses doubt about use of this step, role play and rehearsal may be useful.

Step 5: Professionals and Agencies to Contact for Help

Purpose: List professionals/services to reach out to if previous steps did not resolve the crisis.

Instruct the Veteran to use Step 5 if Step 4 does not resolve the crisis or lower risk.

This section should not be left blank; if the Veteran does not name any other professional contacts, list yourself as a provider to contact, if appropriate to your role. List the numbers in the order the

Veteran would call them.

Ask – Who are the mental health professionals or professional peer supports who should be included in your plan?

Name: ___________________________ Phone Number: _____________________

Name: ___________________________ Phone Number: _____________________

Name: ___________________________ Phone Number: _____________________

Name: ___________________________ Phone Number: ____________________

If you are unable to reach your safety contacts or if you are in crisis, please contact any of the following services:

Veterans Crisis Line: 988, press 1 or 1-800- 273- 8255, press 1

Veterans Crisis Line Text Messaging Service: Text to 838255

Veterans Crisis Line Chat: https://www.VeteransCrisisLine.net/Chat

Call “911” in an emergency

Ask - If you need to go to an urgent care center or emergency department, where will you go?

Facility name: ________________________________________________________

Facility address: ______________________________________________________

Facility phone number: ________________________________________________

Local VA Emergency Number: ________________________________________________

“911” in an emergency

Review: Assess likelihood individual will engage in this step; identify potential barriers to seeking professional help or services and assist in problem solving these barriers. If the Veteran expresses doubt about use of this step, role-play and rehearsal may be useful.

Step 6: Making the Environment Safe

Purpose: Assess whether the Veteran has thought about a method or developed a specific plan to kill himself/herself and reduce access to all lethal means, regardless of Veteran’s stated method(s)/plans(s). Determine the Veteran’s access to lethal means and collaborate with Veteran to find acceptable, voluntary options that reduce access to those means and make the environment safer. These actions may include locking up or finding temporary offsite storage for excess medications, firearms, knives or other weapons. Explain to the Veteran that having ready access to lethal means places the Veteran at greater risk for suicide and does not allow enough time for the

Veteran to use the coping strategies or sources of support listed on the Safety Plan.

Motivational interviewing principles and a Veteran-centric approach are helpful guides to this conversation. If reluctance is expressed, ask the Veteran to identify the pros and cons of having access to the lethal method. Planning barriers to access is a multi-step process and may include follow-up with the Veteran and/or a trusted person to confirm that the action plan was implemented.

TIP: If the Veteran declines to disclose ownership of lethal means, explore his/her concerns. Reframe the clinical rationale and reassure the Veteran that reducing access to means is a highly effective strategy to prevent suicide. Suicide attempts often occur impulsively and a delay in accessing means can provide the individual time to calm and apply the steps in their safety plan.

If the Veteran expresses that a firearm is necessary for self -protection, explore alternatives including alternative means of self-protection that could not be used as a means for suicide.

TIP: Do not limit discussion of lethal object to the one Veteran identifies as most likely. Limiting access to any means immediately available is important even if Veteran states that they would never use that particular means.

Means Safety Messaging for Clinical Staff:

https://www.mentalhealth.va.gov/suicide_prevention/docs/Means_safety_messaging_for_clinical_staf f.pdf

Means Safety Messaging for Veterans:

https://www.mentalhealth.va.gov/suicide_prevention/docs/Brochure-for-Veterans-Means-Safety-

Messaging_508_CLEARED_11-15-19.pdf

Ask – What items in your environment might you use to hurt yourself?

TIP: These may include weapons, firearms, drugs, medications, household toxins, alcohol or other potentially lethal items. If the Veteran has a plan for suicide, be sure to explore access to the means for that plan.

Ask – What can we do to make the environment safer?

TIP: Discuss ways of eliminating, reducing or slowing access to potentially harmful items.

D.15 b) SUICIDE PREVENTION SAFETY PLAN - 36C26225R0004 https://www.mentalhealth.va.gov/suicide_prevention/docs/Means_safety_messaging_for_clinical_staff.pdf https://www.mentalhealth.va.gov/suicide_prevention/docs/Means_safety_messaging_for_clinical_staff.pdf https://www.mentalhealth.va.gov/suicide_prevention/docs/Brochure-for-Veterans-Means-Safety-Messaging_508_CLEARED_11-15-19.pdf https://www.mentalhealth.va.gov/suicide_prevention/docs/Brochure-for-Veterans-Means-Safety-Messaging_508_CLEARED_11-15-19.pdf

Ways to make my environment safer and barriers I will use to protect myself from these other potentially lethal means:

State: VA has some tools to offer you [Veteran] if you have access to certain potential lethal means.

Ask – Do you have access to firearms in your home or elsewhere (e.g., off-site storage, through work, friends or family)?

□ Yes □ No

Discuss firearm safety with the Veteran, including:

• asking how firearms and ammunition are stored

• considering options for improving safe storage such as using gun locks and giving the key to a trusted friend/relative, removing the firing pin and giving to a trusted friend/relative, or temporary off-site storage of the firearm when feasible.

Handout for Veterans and Families Reviewing Lethal Means Safety (Firearms and Other

Household Safety Risks): https://www.mentalhealth.va.gov/suicide_prevention/docs/Brochure-for-Veterans-Means-Safety-Messaging_508_CLEARED_11-15-19.pdf

Means Safety Messaging for Clinical Staff:

https://www.mentalhealth.va.gov/suicide_prevention/docs/Means_safety_messaging_for_clinic al_staff.pdf

If Veteran has access to firearms:

Ask – How do you store your firearms? Do you have any that are stored (select all that apply):

Locked with an external device, such as a cable lock or trigger lock

Locked in a gun safe or lockbox

Unlocked (not using either an external device or a gun safe)

Loaded with ammunition

Unloaded and stored separately from ammunition

Disassembled or nonfunctional

Outside of my immediate home and property (e.g., friend/family, personal storage unit, shooting range, gun shop, with law enforcement, pawn shop)

Other: ____________________________________________________

When a Veteran has access to a firearm they don’t own, ask – Is there anything we can do to engage the owner(s) of the firearm(s) in a discussion about safe storage?

Was firearm safe storage discussed with the Veteran?

□ Yes □ No If not, explain why not: __________________________________________

D.15 b) SUICIDE PREVENTION SAFETY PLAN - 36C26225R0004 https://gcc01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.mentalhealth.va.gov%2Fsuicide_prevention%2Fdocs%2FBrochure-for-Veterans-Means-Safety-Messaging_508_CLEARED_11-15-19.pdf&data=04%7C01%7C%7Cb7c8f9568e26485618e608d8cdfafa69%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C637485825104229641%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C1000&sdata=3Ws54CVP6h4X2cShc9NJsnVyttUi%2BGFcvX792hmz66c%3D&reserved=0 https://gcc01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.mentalhealth.va.gov%2Fsuicide_prevention%2Fdocs%2FBrochure-for-Veterans-Means-Safety-Messaging_508_CLEARED_11-15-19.pdf&data=04%7C01%7C%7Cb7c8f9568e26485618e608d8cdfafa69%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C637485825104229641%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C1000&sdata=3Ws54CVP6h4X2cShc9NJsnVyttUi%2BGFcvX792hmz66c%3D&reserved=0 https://gcc01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.mentalhealth.va.gov%2Fsuicide_prevention%2Fdocs%2FMeans_safety_messaging_for_clinical_staff.pdf&data=04%7C01%7C%7Cb7c8f9568e26485618e608d8cdfafa69%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C637485825104229641%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C1000&sdata=R5W8FjUOW8uRmUJGs%2B8B0EiGYaqVuzD1C3iI93JLQmg%3D&reserved=0 https://gcc01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.mentalhealth.va.gov%2Fsuicide_prevention%2Fdocs%2FMeans_safety_messaging_for_clinical_staff.pdf&data=04%7C01%7C%7Cb7c8f9568e26485618e608d8cdfafa69%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C637485825104229641%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C1000&sdata=R5W8FjUOW8uRmUJGs%2B8B0EiGYaqVuzD1C3iI93JLQmg%3D&reserved=0

Ask – Would you like any gun locks?

o Patient declined o Provider did not offer o Gunlock(s) provided o Veteran requests gunlock(s) but they are not presently available o N/A; other safe storage options in place

Ask – Do you have access to opioids?

□ Yes □ No

If Veteran has access to opioids –discuss opioid safety and provide overdose prevention education.

o Education could not be provided. Reason: _______________ o Education provided to:

Patient

Patient’s caregiver or other designee

The following resources were shared:

Academic Detailing OEND SharePoint – includes naloxone recommendations for use

Naloxone Patient Guide

YouTube video: Introduction to Naloxone for People with Opioid Use Disorders

YouTube video: Introduction to Naloxone for People Taking Prescribed Opioids

YouTube video: How to Use the VA Naloxone Nasal Spray

YouTube video: How to Use the VA Intramuscular Naloxone Kit

Other: _______________________________

Used teach back to ensure information provided was clearly understood

Naloxone prescription:

o Order naloxone prescription o Provider notified of request for naloxone prescription o Has current naloxone prescription (i.e., prescription not used and not expired)

Comment: __________________________________

Please be sure to record any naloxone medication received outside of VA in the “Non-

VA medications” section of the “Meds” tab in CPRS. Add the date the patient received the naloxone as the start date o Patient declined naloxone prescription. Reason: _____________________________ o Other: _____________________________________

These are the people who will help me protect myself from having access to dangerous items:

Name______________________________________ Phone________________________

Name______________________________________ Phone________________________

D.15 b) SUICIDE PREVENTION SAFETY PLAN - 36C26225R0004 https://www.pbm.va.gov/PBM/academicdetailingservice/Opioid_Overdose_Education_and_Naloxone_Distribution.asp https://dvagov.sharepoint.com/sites/vhaacademicdetailing/Education%20Materials/Forms/GroupbyCampaign.aspx?id=%2Fsites%2Fvhaacademicdetailing%2FEducation%20Materials%2FOEND%2FPatient%20Education%2FIB10%2D1539%5FOEND%5FPatient%5FOpioidOverdosePrevention%26ReversingAnOverdose%5FP97059%2Epdf&parent=%2Fsites%2Fvhaacademicdetailing%2FEducation%20Materials%2FOEND%2FPatient%20Education https://youtu.be/-qYXZDzo3cA https://youtu.be/NFzhz-PCzPc https://youtu.be/0w-us7fQE3s https://youtu.be/lg1LEw-PeTE

Choose one below regarding Veteran’s current physical address:

□ Veteran’s current physical address:

Address: ______________________________________

City/State/Zip: _________________________________

Ensure that Veteran’s physical address is up-to-date in the EHR.

□ Veteran declines to share current physical address

Choose one below regarding Veteran’s current phone number:

□ Veteran’s current phone number: _________________________________

Ensure the phone number is up-to-date in the EHR.

□ Veteran declines to share current physical address

Ensure Veteran has been given a copy of the safety plan

Veteran has been given a copy of this safety plan.

□ Yes □ No Comments/explain why no safety plan provided: _________________________

Select Yes if the Veteran received a copy of the Safety Plan in any format, including a copy of the progress note, a handwritten copy filled out in session, etc.

Veteran provides permission and family member/caregiver/friend has been given a copy of this safety plan.

□ Yes □ No □ N/A – no family member/friend/caregiver

Comments: _________________________

Did a family member/caregiver/friend participate in this safety planning session?

□ Yes □ No □ N/A – no family member/friend/caregiver

Comments: _________________________

Other Resources

Virtual Hope Box smartphone application (create a hope box to remember good things in one’s life)

Maketheconnection.net (source of Veteran-related resources and information)

Safety Plan in PTSD Coach: www.ptsd.va.gov/appvid/mobile/ptsdcoach_app.asp

Safety Plan in PTSD Coach Video: https://www.youtube.com/watch?v=IRz9xhlkQ0Y

Firearm Suicide Prevention and Lethal Means Safety: www.KeepItSecure.net

D.15 b) SUICIDE PREVENTION SAFETY PLAN - 36C26225R0004 http://www.ptsd.va.gov/appvid/mobile/ptsdcoach_app.asp https://www.youtube.com/watch?v=IRz9xhlkQ0Y http://www.keepitsecure.net/