Heart Gallery Referral Form

Basic Information & Demographics

First Name*

Middle Name

Last Name*

Preferred Name

Birthdate*

Gender*

Gender Other, (If other, please type in other gender/s)*

*

Race/Ethnicity (please select all that apply)*

Race/Ethnicity Other (If other, please type in race/ethnicity)*

*

Pronouns Youth Uses*

He/Him

She/Her

They/Them

Other or Multiple Pronouns

Pronouns Other (If other or multiple pronouns, please type in desired pronouns)*

*

Sexual Orientation

Sexual Orientation Other (If other, please type in other sexual orientation/s)*

*

Language (please select all that apply)

Language Other (If other, please enter the language/s)*

*

Youth Placement Information
Current Location City*
Current Location Name (e.g., name of foster parent/s or place youth is staying with/at)*
Current Location Type*
Date Youth Arrived at Current Location*

County Worker Information
Enter information for the county worker responsible for making decisions and signing legal paperwork for the youth.
County of Responsibility*
Assigned County Worker First and Last Name*
Assigned County Worker Email*
Other County Workers Assigned to Youth Case
List other county workers involved in case who will be assisting with scheduling Heart Gallery Photo Session (Include First & Last Name, Email or Phone, and Role with Youth).

Recruiter Information
If youth is currently receiving child specific recruitment services, please enter information for the assigned recruiter.
Is Youth Currently Receiving Child Specific Recruitment Services*	YesNo
Child Specific Recruiter First and Last Name*	*
Child Specific Recruiter Email*	*
Child Specific Recruiter Agency*	*

Referral Information
Who is Making Referral?*
I Understand that the Primary Purpose of the Photos from a Heart Gallery Session is Permanency Recruitment and that the Youth Will Receive Copies of the Photos*	YesNo
Had Heart Gallery Photos Taken in Past Year*	YesNo
Can Youth Photos be Placed on Public Facing Websites*	YesNo
Please share anything about the youth's personality, interests or unique needs that will help us decide which Photographer might be the best fit*
Other Notes

Sibling Information
If referring a sibling group, please provide the following in the Sibling Details field: First & Last Name of all Siblings Birth Date of each Sibling Current City for each Sibling
Sibling Group*	YesNo
Sibling Details*	*
Notes regarding siblings (placed together y/n and other things we should know)*	*