Case Name Kelsey Harvey Intake/Investigation ID 2013-XXXXXX

Safety Decision Making Methodology Child Safety Plan Example 3 I. Danger Threat(s) The mother (Kelsey Harvey) is diagnosed Case Name Kelsey Harvey Intake/Investigation ID 2013-XXXXXX with depression and has not been taking Effective Date 01/01/2014 her medication as prescribed. Kelsey has been substituting her medication with Worker Name PI Roberts Safety Plan Purpose Impending Danger alcohol to the point of intoxication. This occurs approximately 2-4 times per week. Child’s Name Date of Birth Age During these times, Kelsey has not been Tangela Harvey 07/14/2010 3 years of able to provide Tangela with appropriate age supervision and regular meals. On several occasions without Kelsey’s knowledge, Tangela has left the home, gone to neighbors asking for food and stating she’s scared. Since Kelsey is the only parent in the home, Tangela has been left without a primary caregiver to provide supervision, If there are more than five children, please list meet her needs and ensure her safety on a all remaining children in this row. regular basis.

II. Safety Plan Actions to keep child safe Who is Resources/Peop Frequency Who is responsible responsible for le who will help of for monitoring the action Intervention (Social Connection) Idlewood Jerri Snelling; PI 8am – 5pm PI Roberts Daycare Roberts (Monday- Tangela will attend Friday) Idlewood Daycare during the day. (Basic Parenting Jerri Snelling Angela Brothers 7:30am & PI Roberts Assistance, Supervision & (Maternal (maternal aunt) 5:30pm Monitoring, Social Grandmother) (Monday- Connection) Friday) Jerri Snelling (maternal grandmother) will provide transportation for Tangela to and from daycare.

When Jerri arrives in the morning, she will ensure Kelsey has taken her medication and assess Kelsey’s mood and behaviors. When Jerri drops Tangela off, she will stay until Tangela goes to bed. During this time, Jerri will provide emotional support for Kelsey and ensure Tangela’s basic needs are being met, including supervision and meals.

Prior to leaving for the evening, Jerri will assess whether Kelsey’s emotional state or behaviors present a threat to Tangela, and will stay if they do to ensure Tangela is provided with supervision. (Basic Parenting Angela Jerri Snelling Weekends PI Roberts Assistance, Supervision & Brothers (maternal 8am Monitoring, Social (maternal grandmother) Saturday – Connection) aunt) 9pm Sunday Angela Brothers (maternal aunt) will stay with Kelsey and Tangela on the weekends to ensure Kelsey is taking her medication as prescribed.

During this time, Angela will provide emotional support to Kelsey and ensure Tangela’s basic needs are being met, including supervision and meals.

IV. Signatures Date

III. Termination ______Termination date______Caregiver Reason Plan is no longer required ______Car egiver

Other reason plan is no longer needed Other ______Worker ______Supervisor