MST Safety Plan

Genesee County Community Mental Health
420 W. Fifth Ave.
Flint, Michigan 48503 / MST - SAFETY PLAN
Immediate / Follow-Up
Name(s) of Family Member(s): / Date Initiated:
MST Therapist: / MST Supervisor:
Target Behaviors:

Complete each portion of the table below:

Who / What (describe the actions) / Where / When (triggers…)

Change in Target Behavior

Monitoring/ Supervision

Searches
Relocate or Secure Potentially Harmful Items (include firearms, drugs, etc., PRN)
Notifications (e.g., police, “Tarasoff”)

Plan to Evaluate MST Safety Plan

Agreement to Participate in the Plan:

Participant (print name) / Signature
1. 
2. 
3. 
4. 
5. 
Therapist/Credentials: / Date:
Supervisor/Credentials: / Date:
Client Name:
DOB: / Section 5
Staff Name: / Last revised: September 22, 2008
Case Number: / Page 2 of 2
Medicaid Number: