MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION CHILDREN WITH PROBLEM SEXUAL BEHAVIORS SAFETY PLAN	Report Date:
Case/Call Number:
Date Completed:
Adults Involved:	Child(ren) Involved:
What is needed to keep all the children in the home safe? Check all that apply Close supervision Re-arrange bedrooms One or more children will be separated
Other:
Who will be responsible for supervising the children?
Name	Relationship
Describe the specific steps that will be taken to supervise the children:
If bedrooms need to be re-arranged, describe the specific steps that need to be taken:
If the children need to be separated, describe the specific steps that need to be taken:
Describe the specific steps that will be taken to monitor access to media:
The family agrees to the following house rules:
What additional steps are necessary to ensure the safety of everyone in the home?
What additional services or supports does the family need?
Who will be helping to implement the safety plan?
How will the parents/caregivers communicate this safety plan with the children in the home?

What is a Safety Plan? It is a plan that both parents/legal guardians may agree to follow to protect their child from an identified threat to your child’s safety. The Safety Plan is not a custody or visitation order. Only a judge has the power to issue such orders. What are the goals of a Safety Plan? a. To protect vulnerable children from identified threat of dangers; b. To make reasonable efforts to address the problems that the family and the Children’s Division have identified as placing the children at risk of removal from the home; What if I change my mind after I agree to a Safety Plan? The Children’s Division has no power to enforce a Safety Plan or punish someone for violating the plan. If you want to withdraw from the Safety Plan you can do so at any time, however prior to terminating the Safety Plan you should contact Children’s Division Worker involved in the safety planning of your child(ren) immediately. If the Plan is not being followed and the Division has reason to believe that failure to follow a Safety Plan may place the child’s safety at risk, the Division may make a referral to the Juvenile Officer, the Juvenile Court or law enforcement for further action. Can the Division change or terminate the Safety Plan? The Children’s Division may terminate or modify the plan at any time. This may include terminating any services provided by the Division or it may involve modifications to the plan in order to address the threat of danger more effectively. The Division will notify all participants of this change. The Children’s Division may take any action believed necessary to carry out its duties and responsibilities as provided by law. What if I have agreed to a Safety Plan, but the other parent either has not agreed to the plan or has violated the terms of the plan? A Safety Plan is voluntary. The Division has no power to require the other parent to agree to follow a Safety Plan, and has no power to punish the other parent for violating the terms of the plan. If the Division has reason to believe that failure to follow a Safety Plan may place the child’s safety, health or welfare at risk, the Division may make a referral to the Juvenile Officer, the Juvenile Court or law enforcement for further action. Should I get an order of protection (sometimes known as an “ex-parte order “or a “restraining order”)? Children’s Division employees are not attorneys and they cannot give you legal advice. That is a question that you will need to talk to your attorney about. What is an order of protection, “ex-parte order” or restraining order”? These are emergency orders that the court can enter to keep someone who is abusing someone else away from them until the court can hold a hearing to decide what to do. Orders can be entered to protect both adults and children. These orders are only entered for a limited period of time. You can apply for an order of protection at the Courthouse. Again, if you are concerned about the safety of you or your child you should get advice from an attorney about whether an order of protection is right for you. Should I involve an Attorney? You have a right to consult with an attorney before agreeing to this plan. The Children’s Division employees are not attorneys and they do not give legal advice. What if I cannot afford an attorney or do not have an attorney? You can call the Missouri Bar Lawyer Referral Service at 573-636-3635 for referral information. You can also call the Legal Aid office that serves your area to see if you qualify for free legal advice or services. The contact information for your local office can be accessed via the internet at: http://www.lsmo.org/directory or you can ask your Children’s Division worker for the number.
Parent 1 Signature	Date	Parent 2 Signature	Date
Other (Specify Relationship) Signature	Date	Other (Specify Relationship) Signature	Date
Other (Specify Relationship) Signature	Date	Other (Specify Relationship) Signature	Date
Worker’s Signature	Date	Supervisor’s Signature	Date