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The document outlines the Level of Service Inventory for Adult Foster Care Behavioral Health Services, detailing the assessment of assistance levels required for Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). It includes various domains assessing personal hygiene, meal preparation, medication management, and habilitative services frequency. The document is structured to evaluate the level of support needed by clients in a foster care setting, with sections for assessor and client signatures.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the assessing agency name and assessment date at the top of the form. This information is crucial for record-keeping.
Proceed to Domain 1, where you will assess the level of assistance required for Activities of Daily Living (ADLs). For each task listed, select the appropriate level of assistance: Full, Partial, Minimal, or None.
Continue to Domain 2 and indicate the frequency of assistance needed for Instrumental Activities of Daily Living (IADLs). Mark daily, weekly, or monthly as applicable.
In Domain 3, specify the hours of program supportive services per day. Choose from options like 12-24 hours based on your assessment.
Finally, complete Domain 4 by detailing habilitative services frequency. Select from daily, weekly, monthly, or never for each service listed.
Once all sections are filled out, ensure signatures are provided at the bottom by the assessor, client, and provider representative along with their names and titles.

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Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (228 Votes)

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