Kinship Home Study Referral Form - Page 1 of 3 (Basic & Contact Information)
Please note: There are three pages to this form. Click save when finished entering information on pages 1 & 2. On the 3rd page is a review of previously entered information. Click Submit once finished reviewing.
Relative/Kin Information - Primary Applicant
First & Last Name
*
Birthdate
Social Security #
Street Address
Apartment/Unit/Suite #
City
State
Select US-State
AK - Alaska
AL - Alabama
AR - Arkansas
AS - American Samoa
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
FM - Federated States of Micronesia
GA - Georgia
GU - Guam
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MH - Marshall Islands
MI - Michigan
MN - Minnesota
MO - Missouri
MP - Northern Mariana Islands
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
PW - Palau
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VI - Virgin Islands
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Enter Region
Zip Code
Phone Number
**
Enter International
Phone Number Type
**
Cell
Home
Office
Email Address
Preferred Contact Method
**
Phone
Email
What is Relative/Kin's Relationship to Youth?
**
Relative/Kin Information - Additional Applicant
If there is a second applicant being referred for a home study, please fill out the information below.
First & Last Name
Birthdate
Social Security #
Phone Number
Enter International
Phone Number Type
Cell
Home
Office
Email Address
What is Relative/Kin's Relationship to Youth?
**
Youth Basic Information & Demographics
If this kin is being referred for a sibling group, please enter information about the oldest youth here. There's a spot for information about the other siblings in the next section.
First Name
*
Middle Name
Last Name
*
Preferred Name
Birthdate
*
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)
**
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)
**
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)
**
ICWA Applies?
*
Yes
No
Unsure
Unknown
Tribal Membership
**
No Tribal Membership
Unknown
Bois Forte Band of Chippewa
Cheyenne River Sioux Tribe-SD
Crow Creek Sioux Tribe-SD
Flandreau Santee Sioux Tribe-SD
Fond Du Lac Reservation
Grand Portage Band of Chippewa Indians
Leech Lake Band of Ojibwe
Lower Brule Sioux Tribe-SD
Lower Sioux Indian Community
Mille Lacs Band of Ojibwe
Oglala Sioux Tribe-SD
Prairie Island Indian Community
Red Lake Band of Chippewa Indians
Rosebud Sioux Tribe-SD
Shakopee Mdewakanton Sioux (Dakota) Community
Sisseton Wahpeton Oyate-SD
Spirit Lake Nation- ND
Standing Rock Sioux Tribe- ND
Three Affiliated Tribes-ND
Trenton Indian Service Area- ND
Turtle Mountain Band of Chippewa- ND
Upper Sioux Community- SD
Upper Sioux Indian Community
White Earth Reservation
White Earth Reservation-SD
Yankton Sioux Tribe- ND
Other
Tribal Membership Other
**
Tribal Affiliation
*
Pottawatomi
Anishinaabe/Ojibwe
Cherokee
Cree
Dakota
Ho-Chunk (Winnebago)
Lakota
Navajo/Deni
Oneida
Other Tribal Identity
No Tribal Identity
Unknown
Tribal Affiliation Other
**
Siblings
If there are multiple siblings being referred for this Relative/Kin, please enter each siblings First and Last Name, Date of Birth, and Relationship to Relative/Kin Home Study in the Sibling Details field.
Sibling Group
*
Yes
No
Sibling Details
**
Notes regarding siblings (placed together y/n and other things we should know)
**
Youth's Current Placement Information
Only
need to fill in placement address info/type if Youth is
NOT
currently placed with referred Relative/Kin.
Has Youth Already Been Placed in the Relative/Kin Home via an Emergency Relative Placement?
*
No
Yes
Date Youth Arrived at Current Location
**
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
Current Location Contact Person
**
Current Location Phone Number
**
Enter International
Email
Current Location Street Address
**
Current Location City
**
Current Location State
**
Select US-State
AK - Alaska
AL - Alabama
AR - Arkansas
AS - American Samoa
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
FM - Federated States of Micronesia
GA - Georgia
GU - Guam
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MH - Marshall Islands
MI - Michigan
MN - Minnesota
MO - Missouri
MP - Northern Mariana Islands
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
PW - Palau
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VI - Virgin Islands
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Enter Region
Current Location Zip Code
**
Referring County Worker
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
First & Last Name of Person Making Referral
*
Street Address
Building/Suite #
City
State
Select US-State
AK - Alaska
AL - Alabama
AR - Arkansas
AS - American Samoa
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
FM - Federated States of Micronesia
GA - Georgia
GU - Guam
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MH - Marshall Islands
MI - Michigan
MN - Minnesota
MO - Missouri
MP - Northern Mariana Islands
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
PW - Palau
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VI - Virgin Islands
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Enter Region
Zip Code
Office Phone Number
Enter International
Work Cell Phone Number
Enter International
Email
*
Preferred Contact Method
**
Email
Office Phone
Work Cell Phone
Referring Worker Role with Youth
*
List other county workers or private agency recruiters involved in case (Include Name, Phone, Email, and Role with Youth). If there are no other workers, write none in the box.
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