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Heart Gallery Referral Form

In order for a youth to be eligible for Heart Gallery services, the primary purpose of the photos must be for permanency recruitment.

Basic Information & Demographics
First Name*
Middle Name
Last Name*
Preferred Name
Birthdate* Calendar
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*
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*  
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*
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*
Had Heart Gallery Photos Taken in Past Year*
Can Youth Photos be Placed on Public Facing Websites*
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
Please fill out if making a referral for sibling set.
Sibling Group*
Sibling Details* *
Notes regarding siblings (placed together y/n and other things we should know)* *
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