MISSOURI DEPARTMENT OF SOCIAL SERVICES

CHILDREN’S DIVISION

CRISIS INTERVENTION FUNDS REQUEST/AUTHORIZATION

DATE OF REQUEST	CASE NAME	DCN
1. TYPE OF CASE (Documentation to be attached):
Investigation/Assessment. Documentation: CPS-1, CPS-1A
FCS Case. Documentation: CD-14,14A,14B
Out of Home Care. Documentation: CD-14,14A,14B
2. There is a risk of child maltreatment within the family due to:
3. The family has attempted to prevent the current crisis by:
4. The family remains in need of such funds (list all resources the family has used to alleviate the need for crisis intervention funds).
ITEM(S) REQUESTED	DOLLAR AMOUNT
VENDOR NAME(S)/ADDRESS
SIGNATURE OF WORKER	DATE
I have reviewed this request and required documentation and agree/deny the request for Crisis Intervention Funds due to:
SIGNATURE OF COUNTY DESIGNEE	DATE
I have reviewed this request and required documentation and agree/deny the request for Crisis Intervention Funds due to:
OTHER COUNTY/REGIONAL SIGNATURE	DATE