Perinatal Cluster

Plan of Safe Care (POSC)

A living document designed to support the well-being of the mother and her family throughout her maternal journey. Complete on screen, then print or save as a PDF. A copy will be housed at the Family & Children First Council, 831 College Avenue, Suite C, Lancaster, Ohio 43130 · 740-652-7286.

Section 1 — Personal Information

Name

Date of Birth

Age

Address

City

State

Zip

Phone Number

Emergency Contact

Relation

Emergency Contact's Phone

Guardian (if minor)

Relation

Guardian's Phone

Insurance

Private Plan

Section 2 — Family (list all people in your home)

Name	Relationship	Date of Birth

Section 3 — Support Person(s)

Name	Relationship	Phone Number

Section 4 — Medical Information

Currently pregnant? (Yes/No)

Due Date

Date of 1st Visit

OB/GYN

Preferred Hospital / Birthing Facility

Primary Care Physician

Current substance use? (Yes/No)

Substance

How long used

History of substance use? (Yes/No)

Date of last use

Medication Assisted Treatment? (Yes/No)

Current medical & mental health diagnoses

Medications

Allergies

Section 5 — Substance Use Recovery Plan

Current Treatment Program / Agency

Program Phone

Counselor / Therapist

Case Manager

Return-to-use plan created? (Yes/No)

Do you have a copy? (Yes/No)

Comments

Section 6 — Health & Safety Plan for Your Infant

Infant's Pediatrician

Preferred Hospital

Safe sleep plan & supplies (crib, car seat, etc.)

Feeding plan

Notes