Domestic Violence Safety Plan Worksheet

GinaMarie Guarino, LMHC GinaMarie Guarino, LMHC

Worksheet published on September 7th, 2021

Worksheet updated on November 23rd, 2021

Domestic Violence Safety Plan Worksheet

People who are in unsafe relationships often feel trapped in their situation. It is common for people who are in a domestic violence situation to stay quiet about their circumstances, which prevents them from reaching out for help. People who are struggling with domestic violence may fear judgment from others or retaliation from their abuser, which causes them to feel like there are no options.

When working with people who may be in a domestic violence situation it is important to have resources that provide information about their options. It takes a lot of courage for victims of domestic violence to talk about their circumstances, so having a resource for planning for safety makes a huge difference for their health and wellness.

The safety plan must take into consideration the individual’s circumstances. Considering the individual’s access to resources, obstacles and responsibilities are all important when developing a plan for managing and leaving a domestic violence situation.

About This Worksheet

This is the Domestic Violence Safety Plan worksheet. This worksheet provides a comprehensive outline of considerations needed to prepare a person to leave a domestic violence situation. This worksheet is a great tool for mental health professionals to use when helping a client determine their best course of action when in a domestic violence situation.

It is important to note that this worksheet is intended to be used as a tool to be used by a mental health professional to help a person in a domestic violence situation prepare to take the best care of themselves. It is a worksheet that should not be used without a mental health professional. This worksheet is a therapeutic tool that can be used to assist the process of safety planning.


A mental health professional trained in the intervention of domestic violence situations should be using this worksheet. This worksheet is to be used to help the process of preparing a person in a domestic violence situation to leave the abusive environment and find a safe space away from their abuser.

Review the contents of the worksheet with your client. Go through each question with the client and fill in the responses of the client to complete the worksheet. Assist the client with developing a plan of action that considers the client’s resources and access to help, along with any children, dependents, or pets that need to be considered. Use this worksheet as a tool for treatment and intervention.

Download Domestic Violence Safety Plan Worksheet

Link To This Worksheet

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