MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION REFERRAL TO THE JUVENILE OFFICER
Date Submitted:	Time Submitted:	Initial Referral Amended/Updated Information
Child(ren)’s Name	DOB	Sex	Race	Hispanic
First Middle Last
1
2
3
4
5
6
Address of Child(ren) (Street, City, State, Zip Code)	Current Location/County of Child(ren)
Parent 1	Child #: 1 2 3 4 5 6 All	Address	Telephone
First MI Last
Street Address City/State/Zip Code
Date of Birth:	Alias/Maiden	Contact w/child(ren):
Parent 2	Child #: 1 2 3 4 5 6 All	Address	Telephone
First MI Last
Street Address City/State/Zip Code
Date of Birth:	Alias/Maiden	Contact w/child(ren):
Child #: 1 2 3 4 5 6 All	Address	Telephone
First MI Last
Street Address City/State/Zip Code
Date of Birth:	Alias/Maiden	Contact w/child(ren):
Child #: 1 2 3 4 5 6 All	Address	Telephone
First MI Last
Street Address City/State/Zip Code
Date of Birth:	Alias/Maiden	Contact w/child(ren):
Child #: 1 2 3 4 5 6 All	Address	Telephone
First MI Last
Street Address City/State/Zip Code
Date of Birth:	Alias/Maiden	Contact w/child(ren):

The Children’s Division, in submitting this Referral to the Juvenile Officer, requests and recommends:
protective custody as reasonable cause exists that the child/children is/are at risk of imminent danger of suffering serious physical harm, threat to life from child abuse or neglect, or have been subjected to sexual abuse or at risk of sexual abuse.
Continued protective custody as protective custody was previously assumed by:
Law Enforcement Officer/Physician	LE/Physician Name	at	-	on
the Juvenile Officer file a petition as reasonable cause exists to believe the child/children are without proper care, custody, and support and intervention is required to prevent personal harm to the child/children.
the Juvenile Officer consider the information contained herein for informal services by the Juvenile Officer.
the Juvenile Officer take no action, as this matter has been referred to the Juvenile Officer as required by law, but the Children’s Division does not believe any action by the Juvenile Officer is necessary. [See additional explanation in Section 2(b).]
The basis for jurisdiction is:
The child is or children are from birth to but not including eighteen years of age; AND
The child is or children are residents of	County, Missouri; OR
The child is or children are found in	County, Missouri; AND
Reasonable cause exists that the child is or the children are in need of care and treatment, in that:
1.	The alleged conduct by parent, guardian, or custodian(s) has subjected the child/children to (check all that apply):
Physical abuse sexual abuse emotional abuse
no suitable caretaker due to arrest/incarceration
dangerous environmental conditions in the family home
exposure to illegal drugs at birth
lack of supervision by refusal to provide for or make appropriate arrangements for care of the child/children
failure to obtain necessary medical or mental health services or education as required by law for the child/ children
the alleged perpetrator has access to the child/children
Other:
2(a)	The facts and circumstances of the alleged abuse and neglect are as follows:
(Specifically describe the alleged abuse or neglect inclusive of all information in your possession as to the nature and severity of the circumstances, all relevant facts and evidence in your possession as to the allegation, the source of all information inclusive of the date the information was received, and the specific risk, safety concerns, and reasons supporting your request to the Juvenile Officer. Attach additional narrative as needed.) ** NOTE: If multiple children are included in the referral, please provide the specific facts and circumstances as to the risk to each child included in the referral.

Enter the Specific Details of alleged abuse/neglect.

Additional narrative is attached.

2(b)	Explain the basis for the recommendation by the Children’s Division that the Juvenile Officer take no action:

Not Applicable

Enter the specific reason(s) the Children’s Division does not recommend the Juvenile Officer take any action in reference to this referral.

3.	Substance use:

Not Applicable Unknown

Describe known substance use history of concerns.

4.	Prior history of abuse or neglect:

(List and briefly summarize the prior reports of abuse or neglect in chronological order from newest to oldest.)

Not Applicable Unknown

Enter prior history of child abuse or neglect:

5.	Criminal history of the parent(s), guardian, custodian of the child(ren)

(List criminal history information of the parent(s), guardian or custodian.)

Not Applicable Unknown

Enter criminal history available at the time of the referral:

6.	Prior history of domestic violence:

(List any incidents of domestic violence reported or reports indicating the same.)

Not Applicable Unknown

Enter Domestic Violence Information:

7.	Evidence and documentation:

(Identify all persons interviewed, reports, photographs, and other information collected or relied upon in the course of the investigation and attach a copy of information relevant to or referenced in the referral to the Juvenile Officer.)

Not Applicable Unknown

List the evidence and documentation information relied upon of collected in the investigation:

Paternity:

Enter all information available as to the paternity of each child subject to the referral:

Absent parent and relative resources:

Describe the efforts of the Children’s Division to locate any absent or non-custodial parent and relatives to be considered for placement if needed:

Indian Child Welfare Act:

Enter any available information regarding Native American or Alaskan Eskimo heritage.

Reasonable Efforts and Services Provided:
The removal request is based on an emergency as this is the first contact with the family by the Children’s Division and the child/children could not safely remain in the family home even with reasonable services being provided to the family by the Children’s Division therefore reasonable efforts were not possible.
The efforts by the Children’s Division to prevent or eliminate the need for removal included:
Case Management Services by the Children’s Division	Date(s) case management services provided:

Describe all services provided including the date and service provider as may be applicable:

I,	, as an authorized representative of the Missouri Children’s Division, do state
that based upon information I have obtained or which has been reported to me, I have reasonable cause to believe the facts and information contained herein support the recommendation of the Children’s Division. The facts and information stated herein are true and correct to the best of my knowledge and belief. I am signing this affidavit understanding that knowingly making a false statement might subject me to the penalties for making a false affidavit.
*Further/updated information will be forwarded to the Juvenile Officer.
Electronic Signature	Electronic Signature	Contact Information
CD Worker	Supervisor	Contact Information
Signed electronically in lieu of written signature.

Additional narrative as to the specific details of the alleged abuse/neglect: