Individual Student Safety Plan
(ISSP)
Written by: [Your Name]
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I. Student Details
A. Student Information
Student Name: | [Student Name] |
Date of Birth: | [Date of Birth] |
Grade: | [Grade] |
School: | [School Name] |
Parent/Guardian Name: | [Parent/Guardian Name] |
B. Emergency Contact
Name: | [Emergency Contact Name] |
Relationship: | [Relationship to Student] |
Phone: | [Emergency Contact Phone Number] |
C. Health Information
Medical Conditions: | [Any medical conditions] |
Medications: | [List of medications] |
Allergies: | [Any allergies] |
II. Risk Assessment
Primary Concerns
Potential Triggers
Large group activities
Conflict with peers
Test anxiety
Protective Factors
Supportive family environment
Strong relationship with school counselor
Interest in extracurricular activities
III. Support Strategies
School-Based Interventions
Implement regular check-ins with student counselor.
Provide access to support groups or peer mentoring programs.
Offer academic accommodations if needed.
Family Involvement
Community Resources
IV. Safety Plan
Warning Signs
Withdrawal from social activities
Decreased academic performance
Expressions of hopelessness
Action Steps
If warning signs are observed, notify designated staff member immediately.
Provide student with a safe space to talk and express feelings.
Contact parent/guardian and emergency contact if necessary.
Crisis Response Protocol
De-escalation Techniques
Remain calm and empathetic.
Use active listening techniques.
Provide reassurance and support.
Emergency Contacts
V. Monitoring and Review
Progress Monitoring
Conduct regular assessments to track progress and adjust support strategies as needed.
Review Meetings
Schedule periodic review meetings with student, parents/guardians, and relevant staff members.
Documentation
Maintain detailed records of interventions, communications, and outcomes.
Plan Templates @ Template.net
