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NMT Referral Form

Basic Information & Demographics
First Name*
Middle Name
Last Name*
Preferred Name
Birthdate* Calendar
Gender*  
Gender Other, (If other, please type in other gender/s)
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)* *
Race/Ethnicity (please select all that apply)
 
Race/Ethnicity Other (If other, please type in race/ethnicity)* *
Language (please select all that apply)
 
Language Other (If other, please enter the language/s)* *
Information about Placement
Current Location Name (e.g., name of foster parent/s or place youth is staying with/at)*
Current Location Type*  
Date Youth Arrived at Current Location* Calendar
Current Location Contact Person*
Current Location Phone Number*
()-ext
Enter Int'l Number
Email
Current Location Street Address*
Current Location City*
Current Location State*
Enter Region
Current Location Zip Code*
Do you expect any changes in youth's living situation?*  
If yes, please provide context.* *
If you selected yes for any upcoming changes in the youth's living situation, please describe.
Referral Information
What are you hoping the assessment will help with?*
This can include the youth’s current strengths and struggles, important highlights about their history and/or current situation, or areas you would particularly want the assessment to focus on (e.g. foster parent is struggling to understand what’s behind behaviors; need support advocating for services at school; youth is transitioning to a new placement/family, etc). The assessor will contact you for additional details after the referral.
Person Responsible for Making Decisions for Youth*  
Person Responsible for Making Decisions for Youth Contact Information*
Please provide responsible person's first & last name and contact information (i.e., phone or email address).
Does this youth currently have any active CPS involvement or expected changes in who will have legal custody of this youth?*  
If yes, please explain.* *
If youth as had active CPS involvement and/or expected changes in legal custody, please describe.
Has there been any big changes in youth's behavior or situation lately?*  
Please describe anything like recent increase in youth's behaviors and severity level & any recent big changes/stressors).
If yes, please describe* *
If you answered yes to change's in youth's behavior and/or situation, please describe.
Referral Source Information
First & Last Name of Person Making Referral*
Role with Youth Being Referred*  
Street Address
Building/Suite #
City
State
Enter Region
Zip Code
Phone Number
()-ext
Enter Int'l Number
Phone Number Type  
Email*
Service Providers
Please list other key service providers currently serving this youth (e.g., therapist/psychiatrist, school social worker/case manager, youth group leader, etc... ). For each service/provider, please list their first and last name, organization, relationship to youth, and contact information.
Youth's Current Service Providers
For each service provider, please list their first and last name, organization, relationship to the youth, and contact information.
Additional Contacts
Please list additional individuals who are familiar with the youth's birth family history and/or current functioning. For each person, please list their first and last name, organization if applicable, relationship to youth, and contact information.
Contacts Familiar with Youth's Current Functioning/Birth Family History
For each contact, please list their first and last name, organization if applicable, relationship to the youth, and contact information.
Miscellaneous Information
Please enter any additional information you think we need to know that would be helpful.
Other Notes
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Ampersand Families | 1751 County Road B West, Suite 300 | Roseville, MN 55113 | Office: 612.605.1904