DATE:  _____________________________________________________________________________________


NAME:   ____________________________________________________________________________________


INTAKE DATE: _______________________________________________________________________________


Please circle.  This is the:    INITIAL safety plan                              REVIEW of the plan                              DISCHARGE plan


EMERGENCY ESCAPE PLAN COMPLETED?                        YES          NO


COPY in file?  YES                 NO                          DATE of Emergency Escape Plan _____________________________




COPY in file?  YES                 NO                          DATE of C. S Assessment: ___________________________________


Safety during a violent incident


I cannot control other’s behaviour, but I can be prepared, in order to increase my safety.


  • I can call 911, or I can teach my children how to safely call 911 if my partner/ex-partner becomes violent with me and in case of emergency.
  • I can establish and use a code word with my children or my friends so they can call for help. The code word is ____________________________________________________________________.
  • My children will have a safety plan and will remove themselves from the area and run to get help.
  • If I see my partner/ex-partner in a public space I can find someone in a uniform or go directly to a well-lit and busy space that I may get some help or support from people to hide or call police. (Consider your physical stamina and abilities as well as the health status of anyone who you would likely have with you.)
  • I can keep my purse and car keys ready and put them ____________________________________ (place) in order to leave quickly.
  • I can tell ___________________________________________________________ about the violence and request that they call the police if they hear suspicious noises coming from my house.
  • If my partner/ex-partner is able to attack me in a public space I can scream loudly and attract attention to the situation.
  • I can take self-defence classes so that I have techniques to better protect myself, increase my confidence, and strengthen my endurance and stamina.
  • I can also ______________________________________________________________________________.



Children’s Safety

  • If I’m in a shelter, I will work with the child and youth team and/or the residential worker to create a safety plan for my children.
  • If I am working with an Outreach worker, I will develop a safety plan for my children with my worker. If Family & Children’s Services (FCS) is working with me and my children, I will inform the Outreach worker, so that I can work with both Outreach and FCS regarding safety for my children.
  • My plan for my children is _______________________________________________________________.
  • I can also _____________________________________________________________________________.

Pet Safety

To keep my pet(s) safe:

  • I can arrange for a friend or relative __________________________________________________ to care for my pets. Give that person all the documentation.
  • I can ask the worker to explore pet fostering.
  • I can also _____________________________________________________________________________.

Safety at work and in public

Women who have experienced physical and psychological violence must decide if and when to tell others about the violence and that they may be at continued risk. Friends, family, your employer and co-workers can help. As a protective measure it may be necessary to break from regular routines and habits when in public “ this may feel frustrating, inconvenient and unfair.


  • I can inform ___________________________________________________________________ (my boss and my co-worker(s)) at work of my situation and also show a photograph of my partner/ex-partner so they are easily identifiable if they appear at my workplace.
  • I can ask ___________________________________________ to help screen my telephone calls at work.
  • When leaving work, I can ___________________________________________________________. I can request an escort to accompany me to my car, bus, etc.
  • I can ask to be relocated or change hours of work.
  • When driving home if problems occur, I can_________________________________________________.
  • If I use public transit, I can_______________________________________________________________.
  • When I visit my medical professionals I will _________________________________________________.
  • I can use different grocery stores and shopping malls and shop at hours that are different than those that I used when residing with my partner.
  • I can avoid wearing headphones that will impair my hearing and/or be a distraction to my surroundings.
  • I can use a different bank and take care of my banking at hours different from those I used when residing with my partner.
  • I can also______________________________________________________________________________.


Technological Safety

In order to increase my safety:

  • I can create a new email, Facebook or instant messaging account.
  • I can check these accounts from a computer which my partner cannot access.
  • If possible, I can get a new mobile phone, especially if my partner/ex-partner gave my phone to me or my phone is on a family or shared plan. I will consider buying a pay as you go card so that phone numbers do not appear on a phone bill.   I can put a new password on my account.
  • If I keep my phone, I can disable Find my Phone.
  • I can disable a location service or GPS.
  • I can change my passwords and PIN numbers on banking accounts, voicemails.
  • I can minimize the use of cordless phones or baby monitors.
  • I can use safe computers, for example at the library or friend’s house.
  • I can also ______________________________________________________________________________.

Safety in my car or when using public transit

In order to increase my safety:


  • I can keep car doors and windows locked at all times.
  • I can change my routine by taking different routes to get places. The routes I travel frequently that I will need to change are: ____________________________________________________________________.
  • When approaching my vehicle, I can do an inspection by looking underneath it as I approach, looking at the tires and at the windows. I will not kneel down beside the car to look under it.
  • I can look into the backseat before getting into the car.
  • I can have my keys ready as I approach my vehicle.
  • Whenever possible I can park in well-lit areas or near a parking attendant’s booth.
  • I can make sure that the automotive centre where my car is serviced does not give out my personal information.
  • If I feel I am being followed, I can drive directly to a police or fire station. Remain inside my vehicle and honk the horn until someone comes to my aid. If I can, I will record the license plate number of any car that is following me.
  • If I travel by public transit (bus) I can sit/stand near the front of the bus so that the driver can assist if necessary.
  • I can also _____________________________________________________________________________.




Safety with a restraining order

I may need to ask the police and the courts to enforce my restraining order. There are criminal justice/ protective actions I can take. The following are some steps that I can take to help the enforcement of my restraining order.


  • I can ask police to assess the severity of my situation.
  • I can ask police to document all warnings given to my partner.
  • I can document the changes I have made to my life as a result of the harassment. I will give this to police.
  • I can ask police to flag my telephone number on their dispatch system.
  • If I have any questions about restraining orders, or how I can get one, I will contact ____________________________________________________________________________________.
  • I can make copies of my restraining order and leave a copy with WCSWR staff. Other copies of my restraining order will be kept ____________________________________ (location). I will always keep one copy of it on or near me. If I change my purse, my protection order is the first thing that will go in.
  • I can inform my employer, co-workers, friends, family, and _____________________________________ that I have a restraining order in effect.
  • If my partner/ex-partner destroys my restraining order, I can get another copy from the courthouse located at _____________________________________________________________________________.
  • If my partner/ex-partner violates the restraining order, I can call the police and report a violation. I can also contact my lawyer and/or call my worker(s).
  • I can inform and provide a copy of my restraining order to people who have contact with my children. The people I will inform about my restraining order include:
    • Daycare/child care provider(s)
    • Children’s school
    • Others:
  • If my partner/ex-partner is involved in the criminal justice system, I can get support and ongoing information from _________________ (Victim Witness Assistance Program, Victim Witness).
  • I can also ___________________________________________________________________________.


Safety in my own residence (living without partner)

There are things that I can do to increase safety at home. It may be impossible to do everything at once, but protective actions can be added step by step.


  • I can change the locks on my doors and windows as soon as possible or request that the landlord do so if I am returning to a home known to my partner.
  • I can install security systems including additional locks, window bars, poles to wedge against doors, an alarm system, check/replace outside light bulbs or sensor lights.
  • I can purchase rope ladders to be used for escape from second floor windows if appropriate.
  • I can contact ______________________________________ to help with purchasing these items and _______________________________________________________ to help with installing.
  • I can teach my children not disclose our address and phone number to my partner/ex-partner and my partner’s family/friends including___________________________________________ and others, including _____________________________________________________________________________.
  • I can inform __________________________________________________________ (neighbours), and ___________________________________________________________ (friends) that my partner/ex-partner no longer resides with me and instruct them to call police if my partner/ex-partner is observed near my residence. I can show a photograph of my partner/ex-partner so they are easily identifiable.
  • I can also _____________________________________________________________________________.


Emotional Safety

The experience of being abused and/or verbally degraded by a partner is usually exhausting and emotionally draining.  The process of building a new life requires much courage, support and energy.  You may have been isolated from family and friends.  It is important to build a support network, little by little.


  • If I feel down and want to return to a potentially abusive situation, I can _______________________
  • When I have to communicate with my partner/ex-partner in person or by telephone, I can __________________________________________________________________________________.
  • For support I can call ______________________________, read______________________________.
  • I can also ___________________________________________________________________________.






Client: __________________________________________    Date: ____________________________________



WCSWSR Worker: _________________________________   Date: ____________________________________



Manager: ___________ (electronic signature) __________    Date: ____________________________________




Skip to content