Member Name:
Date of Overnight Request Submission:
Deparure Date:
Return Date:
Address you will be at:
Reason for Overnight:
Instructions for Creating Your Safety PlanPlease carefully create a comprehensive safety plan to follow while you are away from the program. To ensure it gets approved, it’s crucial to put a lot of thought and effort into your response below.Potential Triggers While Away (list at least 5 and less will result in denial of pass):
1.
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3.
4.
5.
(Examples: Encountering old drinking buddies, passing by bars or places where substances were used, attending events where substances are present.)
Coping Strategies/Plan:1.
(Examples: Call your sponsor or a supportive friend immediately, engage in a healthy activity like going for a walk or doing a mindfulness exercise, use grounding techniques such as deep breathing or focusing on a particular object.)
Steps to Take in an Emergency:• Remove yourself from the triggering situation.• Contact your recovery coach or house manager immediately.• If unable to reach them, call your emergency contact or go to a safe location like a hospital or police station.• Add three more steps personalized to where you are attending:
Additional Notes/Plans:
Emergency contact InformationPrimary Contact Name:
Relationship:
Phone Number:
Address:
Secondary Contact Name:
Important:
Clients are subject to a UA (Urinalysis) upon returning from the outing.Failure to return by the stated date and time will result in immediate action and possible repercussions.All passes must be submitted at least 24 hours before the requested date. Late submissions will be automatically denied.
If you are not meeting sober program requirements your pass will automatically be denied.
Note: The director will contact the client with approval once reviewed. If more detail is needed, there is a higher chance that the request will be denied.
Please sign below confirming you have reviewed this form and understanding of the requirements in order to get pass approved.
Member Signature: