ASPIRANET

Transitional Housing Program Plus Foster Care

PROGRAM

Emergency Information and SAFETY PLAN

Staff: Please complete document with Participant and/or Host Parent.
(Copy to be placed in the youths chart and youths residence binder and in the On-Call Binder)
Date Developed:

Date Completed: ____________________

Child/Youths Name:

DOB:

DOP:

Host Parents:
Aspiranet Social Worker:
Placement Worker:

Placing Agency:

Emergency Instructions: please follow instructions to assist you in an emergency situation.

In an emergency, contact Aspiranet Social Worker(s) at office during regular business hours
from 8am to 5pm Monday through Friday at: ________________________________________
After business hours, on weekends, or holidays, an On-Call Social Worker can be contacted by calling the Aspiranet office and
following the prompt to access the On-call Social Worker.
Aspiranet on-call number :_____________________________________________________
When to notify Aspiranet for On-Call Support:

Your personal safety is a risk you were threatened, followed home, someone is harassing you
Police Involvement: being arrested, questioned, arrived at your home
Illness or injury requiring a visit to the emergency room
You were injured in a car accident
Extreme depression or feeling suicidal
You suffered from a physical assault or rape
Domestic violence/being held again your will at your apartment or somewhere else
A personal crisis and require speaking to a responsible adult immediately
Any of the above occurred to your roommate or host parent and they are unable to call themselves
Something happened to your child while in your care.

Identified Safety Risk Please identify any safety concerns and interventions to be followed during crisis. If there are not identified safety risks at this
time, please mark not applicable. Staff to complete all community numbers and contact information for reference during a crisis.

Danger to Self
Other: __________________

AWOL

Medical (diabetes, severe allergy, etc.)

Not applicable there is no safety risk for the participant at this time

The following plan has been developed for the safety risk identified above:
If young adult is an immediate danger to self or others - call 911.
Mental Health Contact

Name & Phone Number

Emergency Response Team

Therapist
Psychiatrist
Other Mental Health provider
Directives/Comments:
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Placement Agency Contact

Name & Phone Number

Placement Worker
Placement Worker Supervisor
Placement Agency Emergency contact
Directives/Comments:

Medical Contact

Name, Address, Phone Number

Primary Care Physician

Other Medical Provider
Other Medical Provider
Directive/Comments:

Law Enforcement Contact

Phone Number

Local Police or Sheriff Dept. (non-911)

Directive/Comments:
Birth Family/Guardian Name(s)

Phone Number

Directive/Comments:

Support Individuals Name(s)

Directive/Comments:

Other Interventions
Supervision
Respite in home of:
Other (specify):
Directive/Comments:

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Phone Number

Signature of Aspiranet Representative

Date completed

Signature of Supervisor

Date completed

Signature of Host Parent

Date completed

Signature of Participant

Date completed

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