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Fairfield County Ohio Plan of Safe Care (POSC)

Date: //

This Plan of Safe Care is a living document designed to support the well-being of this mother and her family throughout her maternal journey. It serves as a source of information and reassurance, ensuring that she and her care team have a shared understanding of her needs, strengths, and available resources. By fostering collaboration and empowerment, this plan helps create a safe, supportive environment for both the mother and her infant.

A copy of this Plan of Safe Care (POSC) will be housed at the Family and Children First Council located at 831 College Avenue, Suite C, Lancaster Ohio 43130. 740-652-7286

Section 1: Personal Information

Section 2: Family (Please list all the people in your home.)

Row	Name	Relationship	Date of Birth
1
2
3
4
5
6
7
8
9
10

Section 3: Support Person(s) (Someone you trust to help you and/or your children.)

Row	Name	Relationship	Phone Number
1
2
3

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Section 4: Medical Information

Are you currently Pregnant?YesNo	Due Date:	Date of Initial (1^st) Visit:
OB/GYN:	Preferred Hospital or Birthing Facility:
Current Medical and Mental Health Diagnoses	Medications	Primary Care Physician:
1	1	Do you have a *current* substance use?YesNo Substance: (current)How long have you used this substance? NA (current substance use)
2	2
3	3
4	4
5	5	Do you have a *history* of a substance use?YesNo Substance: (history)How long did you use this substance? NA (history of substance use)
6	6
7	7
8	8
9	9	Date of last use:
10	10	Date of last use:
Medication Assisted Treatment (MAT)YesNo		Allergies:

Section 5: Substance Use Recovery Plan NA (Section 5 does not apply)

Current Treatment Program/Agency:

Program/Agency Phone Number:

Address: (treatment program)

Counselor/Therapist:

Case Manager:

NA (case manager)

Have you created a plan in case you return to use?YesNo

Do you have a copy of the plan?YesNo

Comments:

Section 6: Health & Safety Plan for your infant.

Does your infant have a pediatric home?YesNo	Pediatrician/Health Care Provider:
Is your baby up to date on their immunizations?YesNo
Does your infant have equipment for safe sleep?YesNoIf yes, what?	Infant’s Medical Diagnoses	Infant’s Medications
Does your infant have a car seat?YesNoHow old is it?
Have you discussed feeding your infant with a professional?Yes No
Do you have childcare for when you return to work?YesNoWho: (childcare)
Who will be helping you care for your baby at home?Who: (helping care for baby)	Do you have any concerns about your child’s development?Yes No

Does your infant have a pediatric home?YesNo

Pediatrician/Health Care Provider:

Is your baby up to date on their immunizations?YesNo

Does your infant have equipment for safe sleep?YesNoIf yes, what?

Infant’s Medical Diagnoses

Infant’s Medications

Does your infant have a car seat?YesNoHow old is it?

Have you discussed feeding your infant with a professional?Yes No

Do you have childcare for when you return to work?YesNoWho: (childcare)

Who will be helping you care for your baby at home?Who: (helping care for baby)

Do you have any concerns about your child’s development?Yes No

Additional Infant or Child Information:

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Section 7: Resources

Possible Resources

Currently Engaged

Support Needed

Service Provider

(DAILY LIVING)

Employment

Housing

Transportation

Medical Insurance

(TODDLER/CHILD)

Childcare

Dental Home

Medical Home

Mental Health

Preschool/Education

(INFANT)

Breastfeeding Support

Childcare

Medical Home

Parent Education

(MEDICAL)

Dental Home

Medical Home

Obstetrician/Gynecology Home

Substance Use Disorder Treatment (SUD)

(MENTAL HEALTH)

Case Manager

Counselor

Crisis Line

Recovery Support

Domestic Violence Support

(NUTRITION)

SNAP (Supplemental Nutrition Assistance Program)

WIC (Women, Infants & Children)

Section 8: Referrals Made

Date

Agency

Support Needed

Who made the referral?

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Section 9: Stress Management and Self-care

Section 10: Current Support Agency List

Row	Agency	Contact Name	Phone Number	Email
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

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Updated 10/23/2025

Section 11: Acknowledgement

This Plan of Safe Care document is shared with the agencies that you are working with or have requested to work with and with your planned birthing facility or hospital to help support you and your baby’s health, safety and overall wellbeing. An updated Release of Information will be sent along with your Plan of Safe Care document. This Plan of Safe Care will be valid during your pregnancy and until your infant’s first birthday.

*An agency I do not wish to share with:

Mother’s Signature:Date: (mother’s signature) //

Professional Staff:Date: (professional staff signature) //

Professional Staff’s Printed Name:

Title:Agency:

Updated: (Please make names legible)

Date: (Update 1)Name: (Update 1)

Date: (Update 2)Name: (Update 2)

Date: (Update 3)Name: (Update 3)

Date: (Update 4)Name: (Update 4)

Date: (Update 5)Name: (Update 5)

Date: (Update 6)Name: (Update 6)

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Updated 10/23/2025