Protective Service Alert
Confidentiality Notice: This electronic communication is from the Missouri Department of Social Services, Children’s Division, and is only intended for its addressee. This communication may contain information that is privileged, confidential or otherwise protected from disclosure by law and/or DSS policy. If you are not the intended recipient, or the employee or agency responsible for delivering this information to its recipient, do not copy, circulate, forward or otherwise disclose this document. If you have received this message in error, please notify the sender immediately by return email.
Identifying Information:
Parent/Substitute(s) Name	DOB	DCN	Relationship to child(ren)
Child’s Name:	DOB	DCN	Child’s Name	DOB	DCN
Nature of Concern: (runaway, unable to locate family, specific safety concerns...etc.)
Relevant Prior History: Yes No, If yes explain: Brief history of running, frequent relocation...DO NOT include drug use/treatment or protected health information (PHI))
Description of child(ren): (Brief description of children, other persons, vehicle last seen driving in/ license plate...etc.)
Potential locations of child/family: Yes Unknown, If yes explain: (where might the child/family go and why?)
Law Enforcement notified: Yes No (if yes, law enforcement agency)
Juvenile/Family Court notified: Yes No (If yes, Juvenile/Family Court)
Photo of child attached (only if the court has given permission)
If you have any information, please contact:
Children’s Division Worker	County	Phone Number
Children’s Division Supervisor	County	Phone Number

Upon completion, email this form to “DSS.CD.PSA@dss.mo.gov”.