SECTION I: Identifying Information – Completed by CPS/FC Liaison/IL Coordinator
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Date of Intake Assignment: Click or tap to enter a date
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Family First Regional Email (check one below
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_4000_Forms/PPS4311.docx
Names of Children in the family
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Please print to indicate your attendance
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Address, email and phone numbers are optional
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This information is used to include you in any future meetings
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Appendices/Appendix_0M.doc
Return to: Prevention and Protection Services
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I hereby give my permission to the Kansas Department for Children and Families to release the information I have provided
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Your email address
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_0000_Forms/PPS0350.docx
Has this family had a previous TDM
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The TDM Scheduler will invite professionals if email address is available
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Phone number/email address
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For scheduling, email the completed form to
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Appendices/Appendix_0E.docx
402 State Avenue
Kansas City, KS 66101
Phone: 913-279-7227
Email: Kelly.Milner@ks.gov
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901 Westchester Dr.
Salina, KS 67401
Phone: 785-515-6633
Email: Heather.Koffman@ks.gov
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https://www.dcf.ks.gov/services/RS/Pages/RS_Program_Administrators.aspx
Email Address
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SECTION IV: Other Individuals able to provide information on child’s functioning (IE: Foster Parents, School
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Once this form is complete please email to: QRTP@healthsrc.org
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_5000_Forms/PPS5115.docx
DCF Grant Request for Proposal (RFP
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DCF – Prevention and Protection Services (PPS
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Kansas Department for Children and Families
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DCF Pre-Award Manager via e-mail at dcf.grants@ks.gov
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https://www.dcf.ks.gov/Agency/Operations/Documents/WKD GRANT RFP.doc
DCF Grant Request for Proposal (RFP
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Supplemental Nutrition Assistance Program (SNAP) Food Assistance Outreach
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DCF Pre-Award Manager via e-mail at dcf.grants@ks.gov
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https://www.dcf.ks.gov/Agency/Operations/Documents/SNAP Outreach Grant Request for Proposal.docx
All items are attached to an email and sent to corresponding regional email, including “County.SOUL FAMILY SUBSIDY.Youth
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Follow instructions prompted within email
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_6000_Forms/PPS6300.docx
Contact name/number(s) for family
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CPS Specialist’s Email
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☐ No ☐ Yes (If yes, list name
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Dates/Times CPS Specialist/Family Preservation Liaison is available for Initial Family Meeting
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_4000_Forms/PPS4200.docx