Safe Haven Voluntary History Form

 
 
 
Children and Family Services
 
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What would you like to do?

What you need to know

​​​​​​If you surrendered a baby, you can complete this voluntary form to help ensure their health and safety.​ ​​​​​​​​​We understand this has been a difficult dec​ision for you and want to assure you that we will do everything we can to give your baby the best possible care. 

  • This form is completely voluntary.​
  • If you have any questions or concerns, please do not hesitate to contact us at (402) 471-3121. ​


Required Information (to connect the information provided to your baby)

Baby's Information

Pregnancy and Birth Information

Family Medical History

Tribal Affiliation and Culture

Additional Information

Thank you for taking the time to share this information. Your information has been submitted.


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