Heart Gallery Referral Form
Please Note:
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
*
Gender
*
Female
Male
Non-binary/Genderfluid/Gender Queer
Questioning
Transgender/FtM/Assigned Female at Birth
Transgender/MtF/Assigned Male at Birth
Other
Client doesn't know
Gender Other, (If other, please type in other gender/s)
**
Race/Ethnicity (please select all that apply)
*
African Continent - New American
American Indian or Alaska Native
Asian American
Black or African American
Hispanic or Latinx
Native Hawaiian/Pacific Islander
SE Asian-New American
White/Caucasian
Other
Race/Ethnicity Other (If other, please type in race/ethnicity)
**
Pronouns Youth Uses
*
He/Him
She/Her
They/Them
He/They
She/They
They/He
They/She
Pronouns Other (If other or multiple pronouns, please type in desired pronouns)
**
Sexual Orientation
Questioning
Bisexual/Pansexual
Gay/Lesbian
Straight/Heterosexual
Not Disclosed - Youth Too Young
Other
Sexual Orientation Other (If other, please type in other sexual orientation/s)
**
Language (please select all that apply)
English
Somali
Spanish
Hmong
Other
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
*
Adoptive Home
Adoptive Relative's Home
Biological Parent's Home
Biological Relative's Home
Concurrent Planning
Detention or other Correctional Facility
Extended Foster Care/IL
Foster Home - Kin
Foster Home - MITH
Foster Home - Non Kin
Group Home
Homeless/Couch Hopping
Hospital
Living Independently
Pre-Adopt Home
Residential Treatment
Respite
Shelter
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
*
Aitkin
Anoka
Becker
Beltrami
Benton
Big Stone
Blue Earth
Brown
Carlton
Carver
Cass
Chippewa
Chisago
Clay
Clearwater
Cook
Cottonwood
Crow Wing
Dakota
Dodge
Douglas
Faribault
Fillmore
Freeborn
Goodhue
Grant
Hennepin
Houston
Hubbard
Isanti
Itasca
Jackson
Kanabec
Kandiyohi
Kittson
Koochiching
Lac qui Parle
Lake
Lake of the Woods
Le Sueur
Lincoln
Lincoln, Lyon Murray
Lyon
Mahnomen
Marshall
Martin
McLeod
Meeker
Mille Lacs
Morrison
Mower
Murray
Nicollet
Nobles
Norman
Olmsted
Otter Tail
Out-of-State County
Pennington
Pine
Pipestone
Polk
Pope
Ramsey
Red Lake
Redwood
Renville
Rice
Rock
Roseau
Scott
Sherburne
Sibley
St Louis
Stearns
Steele
Stevens
Swift
Todd
Traverse
Wabasha
Wadena
Waseca
Washington
Watonwan
Wilkin
Winona
Wright
Yellow Medicine
Assigned County Worker First and Last Name
*
Assigned County Worker Email
*
Other County Workers Assigned to Youth Case
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
*
Yes
No
Child Specific Recruiter First and Last Name
**
Child Specific Recruiter Email
**
Child Specific Recruiter Agency
**
Ampersand Families
Children's Home Society/Lutheran Social Services
Evolve Family Services
MN County
Nexus (Kindred/Family Focus)
North Homes
Other MN Private Agency
Out-of-State Agency
Out-of-State County
Referral Information
Who is Making Referral?
*
County Worker
Recruiter
Other
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
*
Yes
No
Had Heart Gallery Photos Taken in Past Year
*
Yes
No
Can Youth Photos be Placed on Public Facing Websites
*
Yes
No
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
*
Yes
No
Sibling Details
**
Notes regarding siblings (placed together y/n and other things we should know)
**
Submit
