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* 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/Other 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 Other or Multiple Pronouns   Pronouns Other (If other or multiple pronouns, please type in desired pronouns)* * Sexual Orientation Gay/Lesbian Straight/Heterosexual Bisexual/Pansexual Questioning Not Disclosed and/or Very 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)* *

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