Primary Contacts/Supports:

My main support person is:
Name:	Relationship to you and your child:
Street address City, State ZIP	Phone:	OK to text?	☐ Yes ☐ No
In case of emergency, who would you want to take care of your child?
Name:	Phone:	OK to text?	☐ Yes ☐ No
Relationship to you/your child:
Other household members (Who else is living with your infant?):
Name:	Phone:	Relationship:
Name:	Phone:	Relationship:
Name:	Phone:	Relationship:
Name:	Phone:	Relationship:
Other important people (Who can be a help or support to you or your child?):
Name:	Phone:	Relationship:
Name:	Phone:	Relationship:

The people who participated in the development of this plan and the other people and agencies listed in this plan are your team. They can help provide and connect you with the services and supports needed by you, your child, and your family.

Please consider signing the Consent to Release Confidential Information so that information about your needs and services can be shared with the agencies/services identified in the Plan. This will help them to coordinate and communicate about services provided and supports needed.

You may need to sign additional releases in order for some team members to share information or if additional agencies are added to your team.

Ask for help. Every new parent needs help.

There is help and support available to you, even when you don’t think there is.

Stay connected with your treatment providers and recovery community.

Who else is on your team?

In the chart, below, make a list of people who are helping you or who know something about your life. These can be professionals, family, or friends. If there is a service listed that you think might be helpful, or that you would like to start working with, ask for help connecting with an agency that provides that service.

Role on team / Type of provider	Agency (or relationship)	Contact person name	Phone number(s)	Other contact information (e-mail)	Next appt. date	Progress notes / activities
Primary Care Doctor
OB/GYN/Prenatal Care provider
Counselor / Therapist
Social Worker
Psychiatrist
Medically Assisted Treatment (MAT) Provider
Substance Use Treatment Provider
Peer Support
Probation Officer
Children and Youth Caseworker
Recovery Specialist