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a written statement from a medical health professional concerning the emotional health of the child, applicant/recipient, household member, or immediate family member; a medical record that indicates the emotional health history and reflects the emotional health status of the applicant/recipient or child; a written statement from CSFA or a licensed private social service agency that the customer is being assisted to resolve the issue of placing the child for adoption; or a sworn written statement from an individual, including the applicant/recipient, whose knowledge can provide the basis for a good cause claim. The applicant/recipient may request assistance obtaining verification from CSED.