MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION
OUT OF COUNTY HOME ASSESSMENT REQUEST	Case Number:
Section I– Identifying Information
To:(Name and Address of Circuit Manager in Receiving County)	From: (Name and Address of Circuit Manager or Case Management Agency in Sending County)
Name of Child	DCN	Sex	DOB	Ethnic Group	Already Placed	Date Placed
Parent #1	Parent #2
Address	Address
Section II – Placement Information
Name of Prospective Placement Resource	DOB	SSN	Telephone
Placement Address:
Legal Status:
CD Custody	Parental Rights Terminated
Court Jurisdiction Only	Other
Section III – Services Requested
Relative Home Assessment Relationship
Biological Parent Assessment Adoptive Family Assessment Foster Family Assessment	Kinship Family Assessment Independent Living Arrangement (ILA) Transitional Living Arrangement (TLA)	Divorce Custody Study Family Requests Maintenance
Section IV – Attachments (Mandatory Documentation)
Child’s Social History Family Assessment (CD-14) Initial Child Abuse/Neglect Background Information on adults in the potential resource home	Court Order (Custody order/Most Recent) Preliminary Criminal Background Screening (PCX date): Summary of case history/ family involvement with CD
Other
Name of Sending Worker	Email:	Work #:
Name of Supervisor	Email:	Work #:
Section V – Action By Receiving County
Placement is Recommended	Interview Completed
Placement is Not Recommended	Protective Service Case Opened
Attach Copy of Family Assessment and All Other Appropriate Material
Signature of Receiving Worker
Signature of Supervisor