Here is an example of a Telehealth Safety Plan that can be create with the client.
Telehealth Safety Plan
[practice name, address, city, state, zip code, phone number and website]
Telehealth Safety Plan
[practice name, address, city, state, zip code, phone number and website]
Client Name: _____________________________
Physical Address where the client will be attending their Telehealth sessions?
Street Address: _____________________________ City: ______________ State: ___ Zip Code: ______
Physical Address where the client will be attending their Telehealth sessions?
Street Address: _____________________________ City: ______________ State: ___ Zip Code: ______
Please Note:The client should inform the clinician whenever a change location occurs for a session. Please verify at the beginning of the session where the client is located.
Backup communication method: ____ Phone ____ Email ____ Text _____ Other
Emergency Contact Person for Client:
Name: _____________________________________
Email Address: ______________________________
Phone: ( ) ____ - _________
Phone: ( ) ____ - _________
Do we have permission to contact this person during emergencies? ____ Yes ____ No
Emergency Response Plan: ______________________________________________________________________________________________________________________________________________________________________________
Mental Health Crisis Plan: ______________________________________________________________________________________________________________________________________________________________________________