Family Name:	Date:	Time:
SIGN IN/CONFIDENTIALITY STATEMENT
Confidentiality statement: We the undersigned are participants in the FSTM for the family. We understand that we have the family’s permission to share information here today that will help the family meet their goals. We also understand and agree to keep this information confidential pursuant to the confidentiality laws and policies of the State of Missouri.
Participant Invited	Relationship to Family	*Agree with plan?	Signature signifying attendance and agreement with confidentiality statement
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No	`
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

*If indicated do not agree with the case plan, specifically state the nature of disagreement:

Per Children’s Division policy 6.7.8, a request for review of the FST decision may be made if requester provides specific examples of perceived bias or procedural error per FST policy 4.7.2.