MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION CHILD WITH SPECIAL NEEDS VERIFICATION FORM
SECTION A. CHILD’S INFORMATION This form is provided to collect information that defines or verifies a child with special needs. This form does not prohibit a medical professional from submitting a letter on professional letterhead.
CHILD’S NAME	CHILD’S DATE OF BIRTH	DCN
SECTION B. CHILD WITH SPECIAL NEEDS EXPLANATION (TO BE COMPLETED BY THE ATTENDING MEDICAL PROFESSIONAL, to include the child’s physician, psychologist, psychiatrist, licensed clinical social worker, licensed professional counselor, nurse practitioner, or physician’s assistant.)
EXPLAIN THE MEDICAL CONDITION OF THE CHILD WITH SPECIAL NEEDS. If the child is not functioning at his/her chronological age, at what age is the child functioning?
SIGNATURE OF MEDICAL PROFESSIONAL	DATE
PRINT NAME OF MEDICAL PROFESSIONAL	PHONE NUMBER