MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION SCHOOL REFERENCE REQUEST
FROM:	Resource Licensing Worker	Telephone	Date
Address
City	State	Zip Code
Agency Contact	Office Hours
Please Complete the questions below and return it to us at your earliest convenience
TO:	School Official and School
Address (Street)
City	State	Zip Code
RE:	Child's Name	Date of Birth	Class
Parent(s)	Address
I. The above named family has applied to the Children’s Division to serve as foster/relative/adoptive parents. They have requested that we conduct an assessment of their family. We are enclosing a release of information form signed by the applicant family and are requesting Information about the child’s adjustment in school.
II.	1. Is he/she working up to his/her potential?	Yes No
2. Is his/her parent(s) responsive to seeking assistance relating to any school identified problems?	Yes No
3. How would you describe his/her relationships with the teachers, others in authority and his/her peers?
4. Do you foresee any problems in his/her adjustment which could be caused by placement of another child in the home? If yes, describe:	Yes No
5. Has the parent(s) been cooperative in his/her relationship with school personnel?	Yes No
School Official's Signature	Date
Print/Type School Official's Name:
PLEASE ATTACH SHEETS IF NECESSARY