Safety Plan for Preparation to Leave
Call shelter and let them know and let them know you are ready to leave.
Do you have a car or other transportation? Yes/No Do you have or can you gather the following information?
* Identification for you and your children (birth certificates,
passports, immunization records)
* School records for your children
* Bank cards, bankbook, credit cards, financial documents
* Passports and immigration papers (where applicable)
* Medications, copies of prescriptions
* Lease/rental agreement, house deed
* Address book
* Personal and children’s own special items/toys etc.
* Extra diapers, formula, necessary items for infant care
Personalized Safety Plan: When planning to leave
1. I will choose the code word __________and
(my children, a neighbor or friend, family members) so they will know to call police if I use that word.
2. I will arrange emergency transportation with _______________.
I will keep my car parked __________________in a way that will be easiest to leave quickly.
3. I will lock up any weapons (guns, knives, baseball bat etc.) or
where it will be harder to get these weapons. I will put _________ in _______.
4. I will plan an escape route with my children as follows. I will
tell them it is a
disaster plan so they will not alert my partner that we might leave.
My plan is ___________________________________ continue on the back of this page.
5. I will tell _________________and ______________(friend,
about the violence in my home and ask them to call the police if they hear my code word or notice that anything unusual is happening.
6. I will go to the following safe place
if I have to leave my home (friend, neighbor, relative, motel, shelter).
7. I will open my own bank account at __________________and leave
records with ______________.( friend, family) or hidden in ___________.
8. I will set aside money in ______________(empty lipstick tube or
unpredictable place, at a friend’s house).
9. I will put copies of important papers, birth certificates,
number, health care numbers in___________________________(a safety deposit box, at a
friend’s house, the trunk of my car).
10. I will be aware of my children’s ability to keep information
confidential and will be careful to not share or have them overhear information that I do not want other people to know. This would include information such as ________________________________________________________________________
(plans to leave, location of extra keys, important papers, name and location of a friend who has agreed to help).
11. I will hide an extra car key in _______________________ where I
get it in a hurry. I will also keep my
purse__________________________ where I can quickly grab it.
12. I will have extra key(s) cut by this date _________________
(example of keys – house, car, mailbox, safety deposit box, garage).
I will have important papers photocopied by this date__________________
(examples include birth certificates, immigration papers, passports, health care cards, social insurance number, lease or house deed, prescriptions).
I will have safety plan prepared and practiced by this date________________.
I will have a bank account opened by this date _______________.
I will have talked to friends and/or family and/or neighbor by this date ____________.
I will have essential papers or photocopies, some clothes, special toys and keepsakes (photographs), medication packed and stored at ___________________ by this date ________________.
13. I will review my safety plan every _________________(week,