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Clinician Name
*
First
Last
Supervisor Name
*
First
Last
Client's Initials, Reccuring Appointment Time
Treatment level response?
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?
*
Clinical improvement
Clinical deterioration
Client requested reduced frequency
Client requested increased frequency
Referral consideration
Other
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?
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Yes
No
Is there a current plan, intent, or access to means?
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Yes
No
Has the client engaged in recent self-harm or dangerous impulsive behavior?
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Yes
No
Does the client demonstrate impaired judgment or impulse control that increases safety risk?
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Yes
No
Is the client unable to safely remain between routine outpatient sessions?
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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?
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Yes
No
Do symptoms interfere with activities of daily living?
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Yes
No
Is the client unable to consistently fulfill essential responsibilities?
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Yes
No
Is significant impairment present in social or interpersonal functioning?
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Yes
No
Does the client's level of impairment warrant consideration of functional supports (e.g., FMLA, ADA, school accommodations)?
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Yes
No
Please describe current functional status.
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Domain 3: Co-occurring Conditions
Is there a co-occurring psychiatric condition affecting treatment?
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Yes
No
Is substance use significantly affecting treatment or recovery?
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Yes
No
Is a medical condition contributing to the client's presentation?
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Yes
No
Are cognitive or neurodevelopmental concerns affecting treatment?
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Yes
No
Is coordination with another provider or specialty service clinically indicated?
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Yes
No
Please describe co-occuring conditions.
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Domain 4: Environmental Factors – Stress
Are family or relationship stressors significantly affecting treatment?
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Yes
No
Are work, school, or financial stressors interfering with treatment?
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Yes
No
Does the client experience housing, legal, or safety instability?
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Yes
No
Does the client's environment limit treatment progress?
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Yes
No
Are environmental stressors contributing to worsening symptoms?
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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?
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Yes
No
Does the client have someone available during times of crisis?
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Yes
No
Can the client access practical support when needed?
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Yes
No
Is the client able to utilize available community resources?
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Yes
No
Does the client's current support system promote treatment progress?
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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?
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Yes
No
Has previous outpatient treatment been insufficient?
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Yes
No
Has the client previously required a higher level of care?
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Yes
No
Have previous treatment modifications failed to improve symptoms?
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Yes
No
Does the client require ongoing treatment adjustments due to limited response?
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Yes
No
Please describe overall treatment history.
*
Domain 7: Treatment Engagement
Does the client attend sessions consistently?
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Yes
No
Does the client actively participate during treatment?
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Yes
No
Does the client demonstrate insight into treatment needs?
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Yes
No
Does the client generally follow agreed-upon treatment recommendations?
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Yes
No
Is the client willing to engage in treatment planning?
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Yes
No
Please describe client's engagement to treatment.
*
Treatment Review Integration
Has the Treatment Review been completed within the last 90 days?
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Yes
No
Has the Treatment Review been discussed with the client?
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Yes
No
Have treatment goals been updated based on the review?
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Yes
No
Have identified barriers to progress been addressed?
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Yes
No
Based on the most recent Treatment Review, is the current Level of Care recommendation clinically appropriate? Please explain your clinical rationale.
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Treatment Recommendation
Based on your clinical assessment, what is your recommended treatment plan?
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Continue Current Treatment Frequency
Decrease in Treatment Frequency
Increase in Treatment Frequency
Internal Referral
External Referral
Higher Level of Care Evaluation
Discharge Planning
Treatment Recommendation: Decrease in Treatment Frequency
New Recommended Frequency:
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Every Other Week (Biweekly)
Twice Weekly
Other
Expected Duration:
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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:
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More Than Once Weekly
Schedule Based on Current Availability
Monthly
Other
Expected Duration:
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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?
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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?
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Specialized service not offered by Roamers Therapy
Client preference
Insurance or financial considerations
Availability or scheduling limitations
Other
If you choose "Other", please explain:
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What external service or provider is being recommended?
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Eating Disorder Specialty Treatment Required
Substance Use Disorder Specialty Treatment Required
Specialized Trauma Treatment Required
Specialized OCD Treatment Required
Specialized Personality Disorder Treatment Required
Specialized Child or Adolescent Services Required
Specialized Group Therapy Program Required
Lower-Cost Therapy Resources Required
Psychiatry Referral Resources Required
Other
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?
*
Intensive Outpatient Program (IOP)
Partial Hospitalization Program (PHP)
Residential Treatment
Inpatient Psychiatric Hospitalization
Emergency Department / Crisis Evaluation
Other
If you choose "Other", please explain:
*
Please provide the clinical rationale supporting the recommendation for a higher level of care.
*
Supervisor Clinical Endorsement:
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Endorsed
Not Endorsed
Treatment Recommendation: Discharge Planning
What is the primary reason for discharge?
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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:
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Please provide the clinical rationale supporting the discharge recommendation.
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What discharge planning interventions have been completed?
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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.
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