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
Educational Enrollment Information for School Placement Form
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Mental Health Provider Email Address
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Placement Email
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School Building Contact Email
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ESSA School District Point of Contact Email
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_5000_Forms/PPS5254.docx
Email
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B. Type of Agency ☐Public ☐Private Non-Profit ☐Private Profit
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C. Official Authorized to Sign Application
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F. Type of Application ☐New ☐Revision ☐Continuation of Grant
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https://www.dcf.ks.gov/services/RS/Documents/OIB_AttachmentA.docxView duplicates
who wish to submit comments in writing may do so using the following email addresses
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or other accommodations, please email Barbara.Mah@dcf.ks.gov or call 785-368-7112 or TDD
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https://www.dcf.ks.gov/services/RS/Documents/Register_Notice_for_12-3-15.doc
Department for Children and Families REV. Jul 2025
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This plan shall be collaboratively created by the youth or young adult, the case management team, and
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Email
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_3000_Forms/PPS3059A.docx
How DCF will support My Plan: Completed by
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I have been part of the decision making and understand that the above agreement requires my participation
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Client Email
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Career Navigator Email
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https://content.dcf.ks.gov/EES/KEESM/Appendix/E-9_GOALS-Self-SufficiencyAgreement04-20.docxView duplicates
How DCF will support My Plan: Completed by
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I have been part of the decision making and understand that the above agreement requires my participation
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Client Email
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Career Navigator Email
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https://content.dcf.ks.gov/EES/KEESM/Appendix/E-8 TANF Self-Sufficiency Agreement 03-2019_.docxView duplicates
form is to be sent via encrypted email to DCF.SBDT@ks.gov with the client’s home region as
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https://content.dcf.ks.gov/ees/KEESM/Forms/ES-4412_Client_Turn_Around_Form.docView duplicates
I hereby give my permission to the Kansas Department for Children and Families to release
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your identifying information (name, address, email address and/or telephone numbers), do not
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_0000_Forms/PPS0350.doc
You are receiving this notice because there has been an
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Street Address: City: State: Zip Code: Date Sent: Email address
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Cc: Email copy to DCF Central Collections Unit
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_6000_Forms/PPS6175.doc