Form AAP10 "Prospective or Adoptive Parent(S) Level of Care (Loc) Reporting Tool" - California

What Is Form AAP10?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2021;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AAP10 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form AAP10 "Prospective or Adoptive Parent(S) Level of Care (Loc) Reporting Tool" - California

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State of California – Health and Human Services Agency
California Department of Social Services
PROSPECTIVE OR ADOPTIVE PARENT(S) LEVEL OF CARE (LOC)
REPORTING TOOL
Prospective or Adoptive Parent(s): Thank you for taking the time to help us understand your child’s
care and supervision needs. The questions below are designed to assess the level of care and
supervision provided to your child beyond what is typical for their age and development. Please
complete this questionnaire in the manner that best describes the level of your assistance required to
meet your child’s care and supervision needs. The information shared will help us in the assessment
process to determine the eligible LOC rate for your child. If there is more than one parent, the
completion of the tool should reflect both parent(s) level of activities required to meet your child’s
needs.
Please complete the following questionnaire:
Child/Youth’s Adoptive Name:
Date of Birth:
____________________________________________________
_________________
Parent Name:
________________________________________________________________________________________________________
Parent Name:
________________________________________________________________________________________________________
SECTION I: PHYSICAL DOMAIN
1. Check ALL boxes that apply to your child/youth’s care and supervision needs and that require your
assistance:
Feeding
Toileting
Putting on clothes
Bathing
Grooming
Menstrual care
Mobility (walking, standing, transferring to/from wheelchair)
Use of upper extremities (hands, arms, fingers)
N/A
2. How do you assist your child/youth with the tasks checked in Question #1? Check ALL boxes that
apply:
Supervision of activities
Verbal cueing as needed
Child needs some assistance
Child is not able to complete without help from an adult
N/A
3. How many tasks from Question 1 do you assist your child/youth with on a daily basis?
1 Task
2 Tasks
3 Tasks
N/A
4. Do you arrange and/or facilitate your child/youth’s participation to address developmental needs
e.g., physical, speech and/or occupational therapy?
Yes
No. If no, skip to Question #7
AAP 10 (6/21)
Page 1 of 6
State of California – Health and Human Services Agency
California Department of Social Services
PROSPECTIVE OR ADOPTIVE PARENT(S) LEVEL OF CARE (LOC)
REPORTING TOOL
Prospective or Adoptive Parent(s): Thank you for taking the time to help us understand your child’s
care and supervision needs. The questions below are designed to assess the level of care and
supervision provided to your child beyond what is typical for their age and development. Please
complete this questionnaire in the manner that best describes the level of your assistance required to
meet your child’s care and supervision needs. The information shared will help us in the assessment
process to determine the eligible LOC rate for your child. If there is more than one parent, the
completion of the tool should reflect both parent(s) level of activities required to meet your child’s
needs.
Please complete the following questionnaire:
Child/Youth’s Adoptive Name:
Date of Birth:
____________________________________________________
_________________
Parent Name:
________________________________________________________________________________________________________
Parent Name:
________________________________________________________________________________________________________
SECTION I: PHYSICAL DOMAIN
1. Check ALL boxes that apply to your child/youth’s care and supervision needs and that require your
assistance:
Feeding
Toileting
Putting on clothes
Bathing
Grooming
Menstrual care
Mobility (walking, standing, transferring to/from wheelchair)
Use of upper extremities (hands, arms, fingers)
N/A
2. How do you assist your child/youth with the tasks checked in Question #1? Check ALL boxes that
apply:
Supervision of activities
Verbal cueing as needed
Child needs some assistance
Child is not able to complete without help from an adult
N/A
3. How many tasks from Question 1 do you assist your child/youth with on a daily basis?
1 Task
2 Tasks
3 Tasks
N/A
4. Do you arrange and/or facilitate your child/youth’s participation to address developmental needs
e.g., physical, speech and/or occupational therapy?
Yes
No. If no, skip to Question #7
AAP 10 (6/21)
Page 1 of 6
State of California – Health and Human Services Agency
California Department of Social Services
5. How often do you arrange/facilitate your child/youth’s speech, physical and/or occupational
therapy?
1 time a month
Up to 3 times a month
Up to 4 or more times a month
6. Do you provide or participate in home exercises or physical activities to improve your child/youth’s
physical and/or developmental delays?
At least 1 time a month
At least 2 times a month
At least 3 times a month
7. Do you provide or participate in home exercises or physical activities to improve your child/youth’s
physical and/or developmental delays?
Yes
No
8. Check ALL boxes that apply if you assist your child/youth so they can participate in community
and/or extra-curricular activities:
Coordinate activities in the community related to self-help and/or life skill routines.
Accompany your child/youth and/or provide direct support to enable participation in community
activities.
N/A
9. If your child is age 14 years or older, please answer the next three questions. Check ALL boxes
that apply and that require your assistance:
Managing finances
Accessing transportation
Shopping
Preparing meals
Using communication devices such as a phone, TTY etc.
Managing medication
Completing basic homework
Personal hygiene
10. How do you assist with these tasks? Check ALL boxes that apply:
Supervision of activities
Verbal cueing as needed
Child needs some assistance
Child is not able to complete the activities without help from an adult
11. How many tasks do you assist with on a daily basis?
At least 1
At least 2
At least 3
SECTION II: BEHAVIORAL/EMOTIONAL DOMAIN
1. Does your child/youth have behavioral/emotional challenges as diagnosed by a Licensed
Therapist or MD?
Yes
No
2. Check ALL boxes that apply with the type of behavioral/emotional supports the child/youth
participates in:
Attends therapy
Family therapy
Group therapy for child
AAP 10 (6/21)
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State of California – Health and Human Services Agency
California Department of Social Services
Parent Child Interactive Therapy (PCIT)
Equine therapy
Support group for Adoptive Family
Adoption Promotion and Supportive Services
Other (please describe)
____________________________________________________________________________________
N/A
3. Check ALL boxes that apply for any activities you do to assist your child in addressing behavioral/
emotional challenges:
Arrange, facilitate, provide and/or consult with a therapist and/or other professionals, and
participate in recommended services and activities.
How many times per month? ______________
Redirect, provide prompts through supervision, support, and discipline beyond age/
developmentally appropriate and/or early intervention activities.
How many times per week? _______________
Implement therapeutic intervention plan as outlined by a therapist.
How many times per week? _______________
Provide enhanced supervision to safely manage behaviors for expected and unexpected
stressors in the home, with peers and in the community.
Provide attention and structured support for expected and unexpected life stressors.
Provide extra attention and structured support to ensure safe interactions with peers, pets,
family members, siblings, and community.
Monitor, observe, redirect, console, soothe, prompt, and/or document behaviors and/or
emotional reactions.
Provide continual observation during waking hours.
Provide line of site during waking hours and limited night supervision.
SECTION III: EDUCATIONAL DOMAIN
1. Preschool children: Check ALL boxes that apply:
No preschool children in the home.
Arrange, coordinate, and assist beyond basic activities for your child’s participation in preschool,
other childcare, or educational program to ensure continued attendance.
Up to two additional hours per week
Up to four additional hours per week
Up to six additional hours per week
Maintain equipment, tools, or devices specific to your child’s needs.
Up to two additional hours per week
Up to four additional hours per week
Up to six additional hours per week
AAP 10 (6/21)
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State of California – Health and Human Services Agency
California Department of Social Services
2. School aged children/youth: Check ALL boxes that apply:
No school aged children/youth in the home.
Do you spend on volunteering or otherwise being present in the classroom?
Up to two additional hours per week
Up to four additional hours per week
Up to six additional hours per week
Do you spend on care and supervision of your child/youth for educational activities?
Up to two additional hours per week
Up to four additional hours per week
Up to six additional hours per week
Coordinate and participate in IEP/504 Plan, Student Study Team Resource Specialist Teacher,
behavioral support, Early Intervention Plans.
Up to two additional hours per week
Up to four additional hours per week
Up to six additional hours per week
Do you support participation in school-based extracurricular activities, e.g. sports, music, theater, etc;
Yes
No
Do you assist with participation in community-based volunteer activities for extra credits;
Up to two additional hours per week
Up to four additional hours per week
Up to six additional hours per week
Do you identify/acquire and put into action any remediation plans or activities when needed.
Yes
No
Do you advocate on behalf of your child/youth with teachers and/or other educational
professionals?
Up to two additional hours per week
Up to four additional hours per week
Up to six additional hours per week
SECTION IV: HEALTH DOMAIN
1. Check ALL boxes of the current medical and mental health services for your child/youth:
N/A
Specialist (e.g., neurology, psychiatry, orthopedic, orthodontist, endocrinology, and/or medical
treatments for a lifelong condition):
Two times per year
11 times per year
1
2 times per year
Medical/psychological care to support gender identity
Early Intervention activities
AAP 10 (6/21)
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State of California – Health and Human Services Agency
California Department of Social Services
If the doctor/dentist provides specialty care for your child/youth (beyond routine/preventative
care) describe, and indicate how many appointments a year you coordinate and facilitate:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
2. Check ALL boxes that apply the administration of medications prescribed by a doctor that includes
psychotropic medication for behavioral/emotional health:
Observe, record, and/or report medication effects to doctor and administer
1 medication as needed
1 medication on a daily basis
2 or more medications on a daily basis
Monitor child/youth’s self-administered medication
3. If your child/youth uses equipment and/or a medical device, check the applicable box that best
describes your assistance:
Monitor the child/youth’s use of the prescribed medical device(s) and/or equipment.
Operate and monitor the prescribed medical device(s) and/or equipment for child/youth.
4. Does your child/youth have a severe medical and/or developmental health concern?: Includes but
not limited to: aspiration, suctioning, mist tent, ventilator, tube feeding, tracheotomy, autoimmune
disease, hepatitis, chemotherapy, indwelling lines, colostomy/ileostomy, or burns on more than
10% of body.
Yes
No
Is your child eligible for California Regional Center Services?
Yes
No
Additional comments, concerns and/or assistance you provide that is not covered in the
above questionnaire.
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
AAP 10 (6/21)
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