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

Enter Region

Zip Code

Phone Number**

Enter International

Phone Number Type**

Email Address

Preferred Contact Method**

Phone

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

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

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

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

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

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?*

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**

Current Location Contact Person**

Current Location Phone Number**

Enter International

Current Location Street Address**

Current Location City**

Current Location State**

Select US-State

Enter Region

Current Location Zip Code**

Referring County Worker

County of Responsibility*

First & Last Name of Person Making Referral*

Street Address

Building/Suite #

City

State

Select US-State

Enter Region

Zip Code

Office Phone Number

Enter International

Work Cell Phone Number

Enter International

Email*

Preferred Contact Method**

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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