Level of Care (LOC) Assessment for Children in Foster Care Instructions

Check this box if the child has or will have a behavior modification plan in the home requiring minimal administration by the foster parent. Fill only if 'Mild to Moderate Needs' is 'Yes'

Check this box if the child has or will have a behavior modification plan in the home requiring significant, daily administration by the foster parent, with the foster parent needing instruction and training. Fill only if 'Moderate Needs' is 'Yes'

Check this box if the child requires continual 24-hour direct supervision and structuring of activities, is never left alone due to risks, and requires daily crisis management. Fill only if 'Severe Needs' is 'Yes'

Enter the child's current living arrangement, specifying if it is HMR, traditional, specialized, or another type.

Provide the child's most recent Level of Care (LOC) score.

Enter the full name of the current caseworker assigned to the child's case.

Enter the phone number of the current caseworker.

Provide the name of the agency, region, site, or specific field office associated with the child's case.

Enter the child's date of birth.

Enter the current date.

Provide the full name of the child.

Enter the unique identification number assigned to the child.

Check this box if the child is not exempt from LOC re-reviews and an LOC must be performed at least annually.

Check this box if the child is exempt from LOC re-reviews and does not require re-review with the LOC due to a chronic disability. Fill only if 'Developmental Score' is 'Severe Needs' or 'Medical/Physical Characteristics Score' is 'Severe Needs'.

Please enter the child's disability code(s).

Check this box if the child attends counseling or psychotherapy sessions one to two times a month requiring foster parent participation, or two to three times a month without regular foster parent participation, or if the child is not currently enrolled but will attend at this level. Fill only if 'Minor Needs' is 'Yes'

Enter the developmental score for the child.

Check this box if the child is receiving special education or early intervention services (per 94-142) but is not in a full-day or self-contained classroom, or if the child has a 504 plan.

Check this box if the child is receiving special education or early intervention services (per 94-142) and is in a full-day or self-contained class or has a one-to-one aide throughout the entire day, or if the child is currently applying for special education services due to educational difficulties where the foster parent/worker is frequently called by the school and/or the child is suspended on a regular basis.

Check this box if the child is receiving special education or early intervention services (per 94-142), is experiencing educational problems, is frequently suspended, or is unable to attend public schools and may attend a non-public facility.

Please enter the educational score for the child.

Enter the type service code for Specialized Foster Care. Fill only if 'Licensed' is 'Yes'.

Enter the type service code for Treatment Foster Care. Fill only if 'Licensed' is 'Yes'.

Please enter the full name of the child.

Please provide the identification number assigned to the child.

Check this box if the child has complex medical and/or physical needs requiring daily interventions, total assistance or dependence on the foster parent for safety and care coordination, durable medical equipment, or if they have specific conditions such as terminal illness, organ transplants, cystic fibrosis, HIV infection, or severe cases of sickle cell disease or cerebral palsy. Fill only if 'Medical/Physical Characteristics' indicates a need greater than Minor.

Check this box if the child has an IQ level of 76 or higher with minor social adaptive delays, or has minor difficulties with adaptive functioning in two or more skill areas, or is diagnosed with learning disabilities.

Check this box if the child has an IQ level between 55-75 with mild to moderate delays in social adaptive functioning and mild deficits in two or more life skill areas.

Check this box if the child has an IQ level between 40-54 with moderate delays in two or more life skill areas.

Check this box if the child has an IQ level of 39 or below with significant delays in two or more life skill areas.

Check this box if the child has an increased need for direct supervision and structuring of daily activities due to emotional, behavioral, developmental, and/or special education needs, often needing more direction than average children. Fill only if 'Developmental Special Needs' is not 'Minor Needs'

Check this box if the child has significantly increased direct supervision and structuring of daily activities due to emotional, behavioral, developmental, and/or special education needs, and/or requires at least weekly crisis management, or cannot tolerate unstructured time. Fill only if 'Developmental Special Needs' is not 'Minor Needs'

Check this box if the child has or will have a behavior modification plan in the home which involves minimal administration by the foster parent. Fill only if 'Developmental Special Needs' is not 'Minor Needs'

Check this box if the child requires significantly increased direct supervision and structuring of daily activities due to emotional, behavioral, developmental, and/or special education needs and/or at least weekly crisis management, and cannot tolerate unstructured time. Fill only if 'Developmental Special Needs' is not 'Minor Needs'

Check this box if the child has or will have a behavior modification plan in the home involving minimal administration by the foster parent. Fill only if 'Mild to Moderate Needs' is 'Yes'

Check this box if the child does not require special assistance with personal care beyond what is considered age appropriate. Fill only if 'Medical/Physical Characteristics' indicates a need greater than Minor.

Check this box if the child requires a minimal level of foster parent in-home assistance/supervision due to mild health conditions, physical disabilities, developmental disabilities or delays (mild mental retardation IQ of 55-75), involving areas like special dietary requirements, comforting techniques for young children, daily living skills, or monitoring health status. Fill only if 'Medical/Physical Characteristics' indicates a need greater than Minor.

Check this box if the child requires a moderate level of foster parent in-home assistance/supervision due to moderate health conditions, physical disabilities, developmental disabilities or delays (moderate mental retardation IQ of 40-50), involving areas like major dietary modifications, specialized comforting techniques, continuous monitoring, specialized communication, frequent medical transport, or moderate home adjustments, or if the child requires a wheelchair or is an HIV-exposed infant (18 months or younger). Fill only if 'Medical/Physical Characteristics' indicates a need greater than Minor.

Check this box if the child attends counseling or psychotherapy three to four times a month requiring foster parent participation, or every week or more often not requiring regular foster parent participation, or is not currently enrolled but will attend at this level.

Check this box if the child's current placement is in a licensed home.

Check this box if the child's current placement is with an unlicensed relative.

Check this box if the child is not currently in a foster or relative home.

Enter the effective date for the LOC (Levels of Care) when payment for specialized/treatment foster care can begin.

Check this box if the child has a chronic medical condition that, according to a medical professional, is not likely to improve, making them exempt from LOC re-reviews. Fill only if 'Yes' is 'Yes'.

Check this box if the child has an IQ that is 39 or below, making them exempt from LOC re-reviews. Fill only if 'Yes' is 'Yes'.

Check this box if the child does not need to have a LOC re-review before one year from the date of this current review.

Check this box if the child needs to have a LOC re-review before one year from the date of this current review and specify the number of months for the re-review.

Provide any comments or service recommendations from the LOC reviewer regarding the child's treatment plan.

Enter the score for medical/physical characteristics.

Enter the score for mental health and behavioral needs.

Check this box if the child requires no increased direct supervision or structuring of activities due to emotional, behavioral, or developmental needs. Fill only if 'Developmental Special Needs' is not 'Minor Needs'

Check this box if the child has an increased need for direct supervision and structuring of daily activities due to emotional, behavioral, developmental, or special education needs, often requiring more direction than peers. Fill only if 'Developmental Special Needs' is not 'Minor Needs'

Check this box if the child requires significantly increased direct supervision and structuring of daily activities due to emotional, behavioral, developmental, or special education needs, or at least weekly crisis management, and cannot tolerate unstructured time. Fill only if 'Developmental Special Needs' is not 'Minor Needs'

Check this box if the child requires continual 24-hour direct supervision and structuring of activities, is never left alone due to associated risks, or needs daily crisis management. Fill only if 'Developmental Special Needs' is not 'Minor Needs'

Enter the personal care score for the child.

Check this box if the child attends counseling or psychotherapy sessions one to two times a month requiring foster parent participation at least once a month, or attends sessions two to three times a month not requiring regular foster parent participation, or is not currently enrolled but will attend at this level.

Check this box if the child attends counseling or psychotherapy sessions three to four times a month requiring foster parent participation at least once a month, or attends sessions every week or more often not requiring regular foster parent participation, or is not currently enrolled but will attend at this level.

Check this box if the child is not currently involved in counseling or psychotherapy.

Check this box if the child attends counseling or psychotherapy sessions at least weekly requiring foster parent participation at least three times a month, or attends sessions twice a week or more often not requiring foster parent participation, or is not currently enrolled but will attend at this level.

Enter the psychotherapy/counseling score.

Enter the number of months within which the LOC must be reviewed again. Fill only if 'Yes, Re-review Before One Year' is 'Yes'.

Enter the unique identification number for the reviewer.

Provide the phone number of the reviewer.

Enter the score indicating the level of direct supervision required for the child.

Enter the score related to the child's psychotropic medication needs.

Enter the score reflecting the child's behavior modification requirements.

Please enter the total score for the Levels of Care (LOC).