TREATMENT FOSTER CARE

SERVICE LOG

*****Submit form to LSS by the 25th of the month via email. Fax or mail only if necessary.*****

Name/Address of Person Completing the form:

Are you the youth’s Foster Parent or respite provider?

Foster Parent Respite Provider

(please complete the corresponding box to the right)

Name of youth in care:

Month/Year:

Placement start date: End date:

Respite Taken: Yes No

Dates of Respite: Number of nights:

Name of Provider:

LSS Home

Full-time placement:

Dates of Respite:

Number of nights:

Name of LSS foster home:

Or youth is not in LSS care full time

Respite Placement:

Appointments:

Please fill in the date of any appointments the child had. Also attach the “Foster Child Health Report Ongoing” that should be filled out at appointments. (For full-time placements only)

Medical: / Dental:
Optical: / Psychiatric:
Counseling: / Med Changes:
School: / Court:

Family Contact: Please list the date of any contact between the child and their biological/adoptive family and the type of contact such as visits and phone calls.

Independent Living Skills: Please list out independent living skills that were worked on this month and how the child did. (For youth age 8+)

Strengths, Skills and Successes: Please list out positive strengths, skills, and successes that the child had.

Summary of Month: Please write about the child’s time in your home and community for this reporting period. Feel free to include day to day activities, interactions with others, school reports, day care reports, community outings, and special events. Please feel free to add more pages as needed

Prudent Parenting: (add pages as needed)

For Full time placements only. The Reasonable and Prudent Parenting Standard does not apply to respite providers or youth for which foster parents are providing only respite.

Date / Time / Description of Prudent Parenting Considerations/Process / Who made decision / Parent and/or placing agency notified?

Other/Notes:

*****Submit form to LSS by the 25th of the month via email. Fax or mail only if necessary.*****

Foster Parent Signature: Date:

Supervisor Signature: Date:

For Office Use Only: Level 2 Level 3/4 Level 5 County: Cost Center: 3576 / 3577