Child Welfare Care Plan Form
Complete this form to document the child’s care situation, needs, supports, and follow-up plan.
Child Information
Child's Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Current Living Situation / Placement Type
*
With parent/guardian
Kinship care
Foster care
Residential care
Other
Guardian and Case Contact Details
Primary Guardian/Caregiver Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Parent
Grandparent
Foster Parent
Legal Guardian
Relative Caregiver
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Caseworker/Social Worker Name
*
Care Plan Needs and Services
Main concerns or reasons for the care plan
*
Immediate safety or supervision needs
Required services and supports
*
Counseling
Medical follow-up
School support
Housing support
Visitation support
Transportation
Other
Priority goals for the child
*
Placement, School, and Follow-Up
School or Educational Setting
*
Next Review or Follow-up Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Planned Care Review Frequency
*
Weekly
Biweekly
Monthly
Quarterly
Other
Additional Notes or Special Instructions
Submit
Should be Empty: