MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION CHILD/FAMILY HEALTH AND DEVELOPMENT ASSESSMENT ATTACHMENT B - RELATIVE/KINSHIP INFORMATION
This form contains sensitive and confidential information regarding the child and his family and is protected by the “Health Insurance Portability and Accountability Act.” Neither the form nor its contents may be shared with any person not actively involved in the care and/or treatment of the child.
Child’s Name
Relationship to the Child:	Maternal Paternal Unrelated
Name	Date of Birth
Current Residence	Place of Birth
Race	Hispanic Yes No	Nationality Descent	Religion
Native American Heritage Yes No	Specify Tribe	Occupation
Eye Color	Hair (color/texture)	Complexion
Height	Weight	Body Type
Health: (If under the care of a physician, please give diagnosis)
Education:
Talents and Hobbies
Habits and Personality Traits
Additional Information