Clinician Name

First

Last

Supervisor Name

First

Last

Client's Initials, Reccuring Appointment Time

Date of Request

Current Treatment Frequency

Weekly
Biweekly
Multiple Sessions per Week (2+ sessions/week)
Other

If you choose "other", please explain:

Reason for Review

What prompted this Level of Care Needs Assessment?

Domain status. client

If you choose "other", please explain:

Roamers Clinical Level of Care Assessment Framework

The Roamers Clinical Level of Care Assessment Framework was developed to provide a more structured and consistent approach to clinical decision-making across the practice. This framework is adapted from the Level of Care Utilization System (LOCUS) and has been modified to fit the needs of an outpatient psychotherapy practice. Rather than determining placement across inpatient or residential settings, it helps clinicians evaluate a client’s current clinical needs and identify the most appropriate treatment recommendations within the Roamers model of care. The assessment looks at seven key areas that commonly influence treatment planning: Risk of Harm, Functional Status, Co-occurring Conditions Environment – Stress, Recovery Environment – Supports, Treatment & Recovery History, Treatment Engagement. Each section includes standardized clinical questions designed to support consistent decision-making.

Domain 1: Risk of Harm

Does the client currently report suicidal or homicidal ideation?

Yes
No

Is there a current plan, intent, or access to means?

Yes
No

Has the client engaged in recent self-harm or dangerous impulsive behavior?

Yes
No

Does the client demonstrate impaired judgment or impulse control that increases safety risk?

Yes
No

Is the client unable to safely remain between routine outpatient sessions?

Yes
No

Please provide supporting clinical evidence for risk assessment.

Domain 2: Functional Status

Do symptoms interfere with the client's ability to work or attend school?

Yes
No

Do symptoms interfere with activities of daily living?

Yes
No

Is the client unable to consistently fulfill essential responsibilities?

Yes
No

Is significant impairment present in social or interpersonal functioning?

Yes
No

Does the client's level of impairment warrant consideration of functional supports (e.g., FMLA, ADA, school accommodations)?

Yes
No

Please describe current functional status.

Domain 3: Co-occurring Conditions

Is there a co-occurring psychiatric condition affecting treatment?

Yes
No

Is substance use significantly affecting treatment or recovery?

Yes
No

Is a medical condition contributing to the client's presentation?

Yes
No

Are cognitive or neurodevelopmental concerns affecting treatment?

Yes
No

Is coordination with another provider or specialty service clinically indicated?

Yes
No

Please describe co-occuring conditions.

Domain 4: Environmental Factors – Stress

Are family or relationship stressors significantly affecting treatment?

Yes
No

Are work, school, or financial stressors interfering with treatment?

Yes
No

Does the client experience housing, legal, or safety instability?

Yes
No

Does the client's environment limit treatment progress?

Yes
No

Are environmental stressors contributing to worsening symptoms?

Yes
No

Please describe environmental stressors that effects client progress or treatment.

Domain 5: Environmental Factors – Support System

Does the client have reliable emotional support?

Yes
No

Does the client have someone available during times of crisis?

Yes
No

Can the client access practical support when needed?

Yes
No

Is the client able to utilize available community resources?

Yes
No

Does the client's current support system promote treatment progress?

Yes
No

Please describe environmental support systems that effects client progress or treatment.

Domain 6: Treatment History

Has the client experienced worsening symptoms despite treatment?

Yes
No

Has previous outpatient treatment been insufficient?

Yes
No

Has the client previously required a higher level of care?

Yes
No

Have previous treatment modifications failed to improve symptoms?

Yes
No

Does the client require ongoing treatment adjustments due to limited response?

Yes
No

Please describe overall treatment history.

Domain 7: Treatment Engagement

Does the client attend sessions consistently?

Yes
No

Does the client actively participate during treatment?

Yes
No

Does the client demonstrate insight into treatment needs?

Yes
No

Does the client generally follow agreed-upon treatment recommendations?

Yes
No

Is the client willing to engage in treatment planning?

Yes
No

Please describe client's engagement to treatment.

Treatment Review Integration

Has the Treatment Review been completed within the last 90 days?

Yes
No

Has the Treatment Review been discussed with the client?

Yes
No

Have treatment goals been updated based on the review?

Yes
No

Have identified barriers to progress been addressed?

Yes
No

Based on the most recent Treatment Review, is the current Level of Care recommendation clinically appropriate? Please explain your clinical rationale.

Treatment Recommendation

Based on your clinical assessment, what is your recommended treatment plan?

Treatment Recommendation: Decrease in Treatment Frequency

New Recommended Frequency:

Every Other Week (Biweekly)
Twice Weekly
Other

Expected Duration:

30 Days
60 Days
90 Days
Ongoing

Clinical Rationale for Decrease in Treatment Frequency:

Supervisor Clinical Endorsement:

Endorsed
Not Endorsed

Treatment Recommendation: Increase Treatment Frequency

New Recommended Frequency:

More Than Once Weekly
Schedule Based on Current Availability
Monthly
Other

Expected Duration:

30 Days
60 Days
90 Days
Ongoing

Clinical Rationale for Increase in Treatment Frequency:

Supervisor Clinical Endorsement:

Endorsed
Not Endorsed

Treatment Recommendation: Internal Referral

What is the primary reason for the internal referral?

Clinical specialization needed
Preferred therapeutic modality
Scheduling/Availability
Other

If you choose "Other", please explain:

Please describe the handoff plan:

Supervisor Clinical Endorsement:

Endorsed
Not Endorsed

Treatment Recommendation: External Referral

What is the primary reason for the external referral?

If you choose "Other", please explain:

What external service or provider is being recommended?

Please provide the clinical rationale supporting the recommendation for external referral:

Supervisor Clinical Endorsement:

Endorsed
Not Endorsed

Treatment Recommendation: Higher Level of Care

What level of care is being recommended?

If you choose "Other", please explain:

Please provide the clinical rationale supporting the recommendation for a higher level of care.

Supervisor Clinical Endorsement:

Endorsed
Not Endorsed

Treatment Recommendation: Discharge Planning

What is the primary reason for discharge?

Treatment goals achieved
Client no longer wishes to participate in treatment
Client relocated outside of the service area
Client transferred to another provider
Higher level of care initiated
Financial or insurance barriers
Other

If you choose "Other", please explain:

Please provide the clinical rationale supporting the discharge recommendation.

What discharge planning interventions have been completed?

Progress toward treatment goals reviewed with the client
Maintenance plan completed
If needed, resources provided
Psychotherapy Discharge Assessment shared
Financial or insurance barriers
Follow-up recommendations discussed

Supervisor Clinical Endorsement:

Endorsed
Not Endorsed

Clinical Declaration

I hereby acknowledge that any recommended change in the client’s level of care is intended to address the client’s current clinical presentation and is not considered a permanent treatment decision.

I understand that:

I understand that any recommended change in level of care is subject to the Roamers review and approval process before implementation.
If approved, the recommendation will be considered a temporary clinical intervention based on the client’s current presentation and will not be considered an indefinite or permanent treatment decision.
I understand that the client’s level of care must be reassessed at least every 90 days, or sooner if clinically indicated, and may be continued, modified, or discontinued based on the client’s ongoing clinical needs and progress.

I certify that the information provided in this assessment accurately reflects my current clinical judgment and has been documented in accordance with Roamers policies.

Signature

Clear Signature

Level of Care Needs Assessment and Treatment Planning Reduction & Referrals

Reason for Review

Roamers Clinical Level of Care Assessment Framework

Domain 1: Risk of Harm

Domain 2: Functional Status

Domain 3: Co-occurring Conditions

Domain 4: Environmental Factors – Stress

Domain 5: Environmental Factors – Support System

Domain 6: Treatment History

Domain 7: Treatment Engagement

Treatment Review Integration

Treatment Recommendation

Treatment Recommendation: Decrease in Treatment Frequency

Treatment Recommendation: Increase Treatment Frequency

Treatment Recommendation: Internal Referral

Treatment Recommendation: External Referral

Treatment Recommendation: Higher Level of Care

Treatment Recommendation: Discharge Planning

Clinical Declaration