Mother’s Plan of Safe Care

Early Identification of infants with prenatal substance and alcohol exposure combined with the infant being connected to supported caregivers and appropriate developmental interventions can improve outcomes. The federal Child Abuse & Prevention Act (CAPTA) requires all providers to refer all newborns that meet the criteria.
I. Family Name:	Case #:	Children’s Names or Suffixes:	Date of Safe Care Plan:
II. Plan of Safe Care:	This document assists in guiding and directing appropriate services and supports to provide for the safety and well-being of a mother and infant affected by substance use, withdrawal, or FASD, including services for the infant and their family/caregiver.
Strengths:
Concerns:
Provider / Organization	Responsible Person	Health	Time Period	How Monitored & Action Steps
Provider / Organization	Responsible Person	Substance use, prevention, treatment & behavioral health	Time Period	How Monitored & Action Steps
Provider / Organization	Responsible Person	Family Support	Time Period	How Monitored & Action Steps
III. Plans of Safe Care:	The responsible persons are those on your team and are available to assist you.
Responsible Persons (Print Name & Organization)	Phone No.	Relationship to Plan of Safe Care	Date
LEAD:

Copies to: White-Agency / Pink-Parent / Canary-Other