MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION CHECKLIST FOR PLACING CHILDREN’S DIVISION FOSTER YOUTH IN LICENSED DMH HOMES
1. Date Form Completed:
2. Date of Home Visit:	3. Date of Placement:
4. Resource Provider(s):
5. Placement Provider Departmental Vendor Number (DVN):
Licensing Agency: Department of Mental Health
6. Copy of Current DMH License attached: YES
Foster Youth Information
7. Name	8. Date of Birth	9. Departmental Client Number(DCN)
Household Composition
10. Names of Other Household Occupant(s) Not Staff; Enter First Name & Last Name Initial Only.	11.Status	12.Gender	13.Age
Household Member DMH placement CD youth	M F
Household Member DMH placement CD youth	M F
Household Member DMH placement CD youth	M F
Household Member DMH placement CD youth	M F
Household Member DMH placement CD youth	M F
Household Member DMH placement CD youth	M F
Household Member DMH placement CD youth	M F
Household Member DMH placement CD youth	M F

Comments

14.

15.

Resource Provider / Representative Date Resource Provider/Representative Date 16. 17.
Children’s Division Case Manager Date CD Supervisor Date

This form is to be placed in the Child’s Section of the foster youth case file.

A copy of the current DMH license is to be attached to this form.

A copy of this form is to be sent to the RCST.

This form is to be completed prior to initial placement.

This form is to be completed coinciding with each DMH license renewal.

The Children’s Division accepts the DMH license in lieu of a Children’s Division license with vendor type MM.