Free Individual Student Safety Plan Template
Individual Student Safety Plan
(ISSP)
Written by: [Your Name]
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I. Student Details
A. Student Information
|
Student Name: |
[Student Name] |
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Date of Birth: |
[Date of Birth] |
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Grade: |
[Grade] |
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School: |
[School Name] |
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Parent/Guardian Name: |
[Parent/Guardian Name] |
B. Emergency Contact
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Name: |
[Emergency Contact Name] |
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Relationship: |
[Relationship to Student] |
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Phone: |
[Emergency Contact Phone Number] |
C. Health Information
|
Medical Conditions: |
[Any medical conditions] |
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Medications: |
[List of medications] |
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Allergies: |
[Any allergies] |
II. Risk Assessment
Primary Concerns
History of bullying
Social isolation
Declining academic performance
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
Schedule regular meetings with parents/guardians to discuss progress and concerns.
Provide resources for family therapy or support services.
Community Resources
Refer to external agencies for additional support (e.g., mental health services, social services).
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
Follow school's crisis response procedures in case of emergencies.
De-escalation Techniques
Remain calm and empathetic.
Use active listening techniques.
Provide reassurance and support.
Emergency Contacts
Ensure all staff members have access to emergency contact information.
Display emergency contact numbers prominently throughout the school.
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.
