MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN'S DIVISION CERTIFICATION OF RECEIPT OF SERVICES – CHILDREN'S TREATMENT SERVICES
CONTRACTED PROVIDER NAME	CONTRACT AND/OR VENDOR NUMBER
NAME OF INDIVIDUAL WHO PERFORMED DIRECT SERVICE AND LICENSING CREDENTIALS (Example: LPC, LCSW…etc) If this field is not filled out, the provider's invoice may be returned to the provider by the Division.
CASE/FAMILY NAME	Date of Service (m/y) /
DATE	CLIENT SIGNATURE*	SERVICE DESCRIPTION	SERVICE LOCATION	TIME IN	TIME OUT
*The signature of the individual receiving this service, or if the individual is a child unable to sign for him/herself, parent or parent-substitute is required to sign this form. The parent or parent substitute shall not be the provider or an employee of the provider.