FST Cheat Sheet - DOC

							                                Family Service Team (FST)/
                                   Level of Care (LOC)
                                         Staffing

Staffing Date:                            DCM:                                         Unit #:
Case Name:                                Court Case #:
                                                                                               Date Placed
                                     Date of           Placement            Placement
          Child Name          DOB                                                               with this
                                     Removal         Provider Name            Type
                                                                                                Provider
1
2
3
4
5

Date of CBHA(s):
CBHA Recommendations (or attach recommendations page from CBHA):


Current Legal Status:
Current Permanency Goal:                                  Case Plan Expiration Date:
Participants:
                                     P    I                                                              P   I
Mother:                                                   TCM:                                            
Father:                                                   I & P:                                          
DCM:                                                       CPA:                                           
DCMS:                                                      CLS:                                           
GAL:                                                    CBCCF:                                            
Caregiver:                                              CBCCF:                                            
Therapist:                                      Other (Identify):                                         
Adoption:                                       Other (Identify):                                         
IL:                                             Other (Identify):                                         

Summary of Reason for Involvement:




CBCCF FST/LOC Staffing Form                                                            Revised 2/18/11