MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION HEAD START/EARLY HEAD START REFERRAL FORM
Date:
Purpose: This form is to be used staff to refer a child to Head Start (HS)/Early Head Start (EHS) program. While children in foster care are categorically eligible for HS/EHS services, this form does not guarantee a placement slot. This form is designed to ensure pertinent information is made available to HS/EHS in a consistent manner.
Child’s Name	DOB	DCN
Parent/Guardian Name
Biological Foster Resource
Parent/Guardian Phone	Parent/Guardian Email
Cell Home
Parent/Guardian Address (Address, City, State, Zip)
If Foster/Resource Parent Above, Biological Parent Name	Biological Parent Phone
Cell Home
Children’s Division Worker Name	Supervisor Name
Children’s Division Worker Email	Children’s Division Worker Phone	Best Way to Contact
Email Phone
Services Needed
Early Head Start (Birth – 3 years) Head Start (3 – 5 years)
Other resources (explain in additional information section)
Referral Information
TANF/SSI	Homeless	Foster Child/Kinship Care
Open Children’s Division Case Alternative Care Family Centered Services	Intact Family Open Hotline	Eligible to receive child care assistance
Head Start/Early Head Start Results (to be completed by Head Start staff)
Referral Received Date:
Children’s Division Follow-up Date:
Family Contact Date:
Program Option Referred To:
Site Referred To:
Application taken:
Enrolled/Waitlisted:
Head Start Staff Name	Supervisor Name
Head Start Staff Email	Head Start Staff Phone	Best Way to Contact
Email Phone
Additional Information
Parent Signature	Date