Columbia County Family Center
Serving Columbia & Montour Counties
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Plans of Safe Care Referral Form
Release/Consent to Disclose Information
PLAN of SAFE CARE PARENT/CAREGIVER INFORMATION
CHILD INFORMATION
REFERRAL SOURCE INFORMATION: (IF APPLICACABLE)
Brief Explanation of Current Status of the Referred Parent/Caregiver and Infant/Child which Promted Referral
Any Immediate Saety Issues Identified?
Was the Parent/Caregiver Informed of the POSC Referral?
Yes
No
Has a ChildLine notification been made?
Yes
No
Was there a Release Signed? Please attach below
Yes
No
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