CHILDREN’S DIVISION

ADOLESCENT FST GUIDE &

INDIVIDUALIZED ACTION PLAN

Youth Name:	DCN:
Youth Email:	Worker:
Date Completed:	Period Covered:	to
Family Support Team Members:
An individualized family support team must be developed for each youth in the custody of the Children’s Division. This team must consist of the core team members (parents, legal counsel for the parents, foster parents, legal guardian for the child, GAL, and CASA representatives) in additional to the specialized team members. The additional team members must consist of individuals connected to the child’s life, members of community resource agencies appropriate to the child’s goal, and a designated support system selected by the youth. The youth with team members' assistance should identify at least 3 individuals who can be used as supports, mentors, and emergency contacts for permanent connections. Youth must be able to contact the listed individuals whenever needed. Individuals must agree to be listed as a contact and should be invited to participate in FSTMs. This is a mandatory field.
The child specific FST Members for this youth are:
Name & Relationship/Title:	Address and Email of Individual or Agency:	Telephone Number:
(Youth)
(Parent)
(Parent)
(Legal Guardian of the Child)
(Youth Support)
(Youth Support)
(Youth Support)
(Family Support)
(Case Manager)
(Supervisor)
(Parent Attorney)
(CASA)
(Foster Parent/Caregiver)
(GAL)
(Juvenile Officer)
(School Personnel)
(Therapist)
(Voc/Guidance Counselor)
(Dept. Mental Health)
(Division of Workforce Development)
(Health Department)
(Other Community Resource)
(Family Support Division staff)
(CFCIP staff)

Youth Advisory Board Participation:
Area Youth Advisory Board Member	State Youth Advisory Board Member
Media Profile Release obtained	Media Profile Release obtained

Youth With Special Needs:
Referral to CFCIP will not be made due to youth incapacitation: Yes Decision date:	Describe reason:

Community Activities and Agencies Youth Is Involved With (List):

Strengths/Needs Assessment Completed:	Yes	Date of Completion:
No

Ansell-Casey Life Skills Assessment:
The Ansell-Casey Life Skills Assessment (ACLSA) must be completed for all youth ages 14 and older who are in the custody of the Children’s Division. It is crucial that at least one caregiver complete the caregiver portion of the ACLSA. The ACLSA can be accessed at www.caseylifeskills.org.
Youth ID #	Organization ID#
Youth has completed ACLSA (date).
If not, assessment will be completed by (date).
Youth is incapacitated; ACLSA will not be completed.
Assessment will be administered by (who).
Caregiver has completed caregiver portion of ACLSA (date).
If not, caregiver will complete ACLSA by (date).
Results of ACLSA should be reviewed by the team. Team members should select 3 to 5 skills to work on at each FST. The selected skills should be chosen based on the goal and permanency plan of the individual child. A plan must be in place on how the skill will be taught, who will teach the skill, a time frame for completion, and how the results will be measured. If the caregiver has a current license to provide care for older youth contract, the caregiver is required to report monthly on progress of life skills attainment.

Life Skills Assessment Worksheet:
Education
Has attended current school for how long?
Has been expelled, suspended, or excluded from school this past year?
If yes, enter school year: How many times in this school year?
Has missed days this year
Reason for the absences (including reasons for expulsion and suspensions)
Steps taken to address absences?
Has experienced change in schools due to change in foster placement?
If yes, how many times
Efforts were made to maintain youth in original school. List efforts:
Records were transferred to new school district. Date Requested: Date Received:
Change in school resulted in absences/truancy/retention
If yes, explain:
Change in school affected graduation time frames
Has safety concerns at school
Has been a victim of a crime at school
Grade level of current performance
Date of last educational evaluation or assessment?
Youth has an IEP
If yes, IEP is current ; IEP is being followed
Youth receives Special School District services
Youth receives tutoring or support services
If yes, in what subjects?
Has reviewed own educational records
If 18 or older, has received a copy of educational records
Has received credits at school and needs Credits to graduate
Youth receives passing grades; List grades:
Caregiver or other person is monitoring progress in school
Youth has consistent transportation to/from school
Who is responsible for transporting?
Youth has appropriate clothing for school
Youth has necessary supplies/equipment to be successful
Youth is involved in extracurricular activities
If yes, which activities?
Youth receives needed support to continue activities, such as transportation, additional equipment?
Youth has completed or is currently receiving services through any of the following?
Homebound or home-schooled services
GED – date obtained
If not yet obtained, when are they attending classes
When will they take the test
High School diploma – date obtained
Youth’s Post-Secondary Plan:
College
Vocational Training
Employment
Military
Youth is currently receiving services through any of the following:
Vocational Training or Services
Services received:
(Service)	Date obtained
(Service)	Date obtained
(Service)	Date obtained
Training received:
(Training)	Admission Date
Completion Date Certificate Received
(Training)	Admission Date
Completion Date Certificate Received
Dual Enrollment (College courses taken while in High School)
List college, date, credit hours that youth has received:
College: Dates of participation: to Credit hours:
College: Dates of participation: to Credit hours:
College: Dates of participation: to Credit hours:
College
Name of College/University
Admission Date
Graduation Date
Degree Received
Post-secondary Education and Vocational Training Preparation:
Tasks to Complete for Admission:
College admission standardized test (ACT/SAT) Date:
Application Date:
Reference Letters Requested Date:
Facility/Campus Tour Date:
Other information still needed Explain
Tasks to Complete for Financial Aid:
FAFSA Date:
Education and Training Voucher application Date:
Other Scholarships Applied for:
Date:
Date:
Date:

Daily Living
Spends within budgeted amount for food
(Budgeted amount $ )
Shops for personal necessities
(Amount budgeted $ ; Amount spent $ )
Shops for own clothes
(Amount budgeted $ ; Amount spent $ )
Has an identified plan for moving out
(Move out date )
Start up costs have been budgeted (Amount $ )

Household Items Inventory**:
Furniture:	Bedroom items:	Living Room/Office:
Has Needs	Has Needs	Has Needs
Bed	Alarm clock	TV
Dresser	Sheets	Stereo
Couch/Sofa	Pillows	Lamps
Chairs	Blankets	Desk
Dining table/Chairs	Mirror	Computer
End/coffee tables	Hangers
Kitchen Items:	Appliances:
Has Needs	Has Needs	Has Needs
Coffee mugs	Baking pan	Refrigerator
Glasses	Casserole dish	Stove/Oven
Cookbook	Silverware	Microwave
Sauce pan(s)	Strainer	Washer
Steak knives	Measuring cups	Dryer
Knife set	Bowls	Toaster
Paring knife	Pitcher
Trash can	Leftover containers	Cleaning Items:
Ice cube trays	Has Needs
Can opener	Other:	Sponges/Rags
Cutting board	Broom
Measuring spoons	Dustpan
Frying pan	Mop
Cookie sheet	Bucket
Pot holders	Toilet brush
Spatula	Scrub brush
Serving spoons	Dish soap
Wooden spoons	Floor cleaner
Slotted spoon	Furniture polish
Vegetable peeler	Trash bags
Mixing bowls	Bath soap
Mixer	Laundry detergent
** Youth has ownership of these belongings

Money Management:
Has a checking account at bank
Maintains a positive balance, records all transactions
Has written bad checks
Average monthly balance
Has a credit card
If yes, where Amount owed
Has established a monthly budget based on income/expenses
Income $ Expenses $
Makes scheduled payments as necessary
Has knowledge of Chafee Aftercare services
Knows who to contact if need to access crisis funds through Aftercare Program

Credit Reports:
Complete this section for youth age 16 and older. Federal law requires that a copy of a consumer credit report be received each year until discharged from foster care and assistance provided in interpreting the credit report and resolving any inconsistencies.
Credit report received at age 16	Date Received:	If not completed, explain:
Assistance provided in interpreting and resolving discrepancies	Date Assistance Provided:	If not provided, explain:
Credit report received at age 17	Date Received:	If not completed, explain:
Assistance provided on interpreting and resolving discrepancies	Date Assistance Provided:	If not provided, explain:
Credit report received at age 18	Date Received:	If not completed, explain:
Assistance provided on interpreting and Resolving Discrepancies	Date Assistance Provided:	If not provided, explain:
Credit report received at age 19	Date Received:	If not completed, explain:
Assistance provided on interpreting and resolving discrepancies	Date Assistance Provided:	If not provided, explain:
Credit report received at age 20	Date Received:	If not completed, explain:
Assistance provided on interpreting and resolving discrepancies	Date Assistance Provided:	If not provided, explain:

Housing
Has a plan on where to live
Has ever signed a lease
Has an adult willing to co-sign a lease
If going into an ILA or being release from custody:
Has found an apartment
Understands the lease
Landlord fixes problems
Has a working smoke alarm
Has a safety plan for fire/tornado
Rent is paid on time; Amount $
Utilities are paid on time; Amounts
Other monthly bills:
Has a roommate
If yes, how are expenses divided:
Problems encountered:

Self Care/Health
Youth has copy of:
Certified Birth Certificate
Social Security Card
Drivers License/Non-driver License
Emergency phone numbers
Immunization Record
Has received health care treatment options education
Schedules own doctor and dental appointments
Last saw a doctor
Last saw a dentist
Last saw an Optometrist/Ophthalmologist
Last saw an OB/GYN
Has been diagnosed with a medical issue
If yes, list diagnosis
Is taking the following medications:
Schedules own counseling appointments as recommended
Has health insurance through employment or other means
If released from care, is aware of MO HealthNet eligibility
Has plans on how to maintain medical treatment and/or Medications after released from care
If yes, describe plan
Household expectations with logical rewards/consequences are used
Has regularly scheduled blocks of time to exhibit ability to take care of self without the supervision or presence of caregiver or other adult. Dates:
Has copy of own medical history
If not, describe plan to obtain
Has good hygiene
Is registered to vote
Is registered for selective service
Knows who elected officials are and how to contact them
Has received a current clothing allowance
Date next clothing allowance due
Has current legal trouble
If so, list:
Knows penalties for breaking the law (trespassing, shoplifting, possession of drugs, stealing, receiving stolen property, etc.)
Has been tested for or diagnosed with a disability
Diagnosis:
Understands the disability
Receives special help at school for the disability
Receives other special services for the disability. List:
Has applied for or receives SSI

Social Relationships
Has relationship with biological family
Is involved in a religious organization
Is involved in other organizations
Leisure time is spent how:
Has a hobby. List:
Refrains from physical violence
Is pregnant now
If yes, was this a planned pregnancy
Has discussed pregnancy options with someone (keeping the child, adoption)
Receiving prenatal care name of doctor:
Has previously given birth (or fathered a child)
If yes, do you live with the child yes no
If no, what are the circumstances
Do you have contact with the child
Is child in the custody of the Children’s Division yes no
Describe efforts for keeping the family unit together
Who cares for the child while attending school or working
Has established paternity
Legal
Genetic
For females – do you want the father to have access to the child ; does the father want access
For males – Do you want to see your child ; does the mother allow you to have contact with your child
For males – Have you registered with the Putative Father Registry
Is enrolled in parenting classes
Has been referred to Parents as Teachers
Has knowledge of child development

Transportation
Arranges for transportation needs
Has a learner’s permit (Date obtained )
Has a driver’s license (Date obtained )
Pays insurance on vehicle
Amount $ ; Agency
Has developed realistic plan for purchasing vehicle
How much $ is needed $
Has obtained own vehicle. Payments a month
Spends for transportation needs within budgeted amount
Amounts $
Has money for gas
Does proper maintenance on vehicle
Relies on public transportation
Relies on others for transportation
If yes, are they reliable?
How much do you pay them?
Has backup transportation, describe:

Career Planning/Work Life
Has met with guidance/career counselor at school
Has career goals and a plan to accomplish goals
If yes, career goal is
Plan to accomplish is
Has thought about potential jobs after emancipation/graduation
Has applied for jobs
Has people who can provide references
Has had job training
Knows about Job Corps, Americorps, US military
If currently employed, where
Hourly pay Hours per week
Has problems at work; List:
Knows company grievance policy
Knows legal rights as an employee

Goals of the Youth
Goal 1:
Domain:
Objective:
Tasks to accomplish the goal	Who will do the Task	Service/Resource To Be Accessed	Date To Be Completed	Accomplished
1.
2.
3.
4.

Goal 2:
Domain:
Objective:
Tasks to accomplish the goal	Who will do the Task	Service/Resource To Be Accessed	Date To Be Completed	Accomplished
1.
2.
3.
4.

Goal 3:
Domain:
Objective:
Tasks to accomplish the goal	Who will do the Task	Service/Resource To Be Accessed	Date To Be Completed	Accomplished
1.
2.
3.
4.

Goal 4:
Domain:
Objective:
Tasks to accomplish the goal	Who will do the Task	Service/Resource To Be Accessed	Date To Be Completed	Accomplished
1.
2.
3.
4.

Agreement and Signatures:
We agree to follow the Individualized Action Plan as completed for the time period	to
Youth	Date
Case Manager	Date
Supervisor	Date
Caregiver	Date
Signatures of others who agreed to provide services during this plan period:
Name	Date
Name	Date
Name	Date
Name	Date
Name	Date
Name	Date
Name	Date
Name	Date
Name	Date
Name	Date