MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION Level of Care Determination Form
Name of Assessor:	Date Completed:
Email:	Phone Number:
Youth Name:	DCN:
Youth’s Current Placement Name:	Type of Placement:	DVN:	Date Placed:
Selection/Screening Team Members in Attendance:
Presenting Behaviors Not Included in the CPSI Checklist (check all that apply):
Destructiveness	Personal hygiene	Other
Poor social skills	Soiling	Other
Eating challenges	Bedwetting	Other
Please describe the youth’s presenting behavior. Give examples of each of the problems you checked:
What is the youth’s permanency plan?
Please list any placement considerations needed for this youth (i.e., travel, visitation arrangements)?
What type of family will best fit this youth’s needs? (i.e. home with no young children/pets, two parent family, etc.)
When we think about the situation this family/youth is facing:
What are we worried about?	What’s working well?	What needs to happen?
Level of Care Determination and Approval:
Traditional Foster Home Medical Foster Home Elevated Needs Level A Elevated Needs Level B
Treatment Foster Care / Submit completed CS-9 packet and Level of Care Determination form to TFC Agency Transitional (Parent/Subsidy) Relative Foster Family Traditional TFC Subsidy In-home Is there already a TFC placement provider identified? Yes No If relative, are they licensed? Yes No Will the TFC agency need to complete the relative home assessment/licensure? Yes No Does Not Meet Criteria/Other
TFC Caregiver:	DVN:	Address:	Phone:
Licensing Worker:	Phone:	Email:
Refer for Residential / Submit completed CS-9 packet and Level of Care Determination form to the RCST Please describe how the child’s needs are unable to be met in a community setting:
Signature of Assessor:	Date: