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Relative Search & Engagement Referral Form - Page 1 of 3 (Basic & Contact Information)

Please Note: Our PPAI Contract with DHS requires every youth referred for Relative Search & Engagement:

  • Be under guardianship of the Commissioner or Tribal Guardianship and
  • Be 6 years of age or older or part of sibling group where at least one sibling is 6 years of age or older.
Please submit the referral after there has been a Termination of Parental Rights (TPR) and when you have time to fill out both pages of the referral form, especially page 2: Relative & Kin Contacts and Support.
  • Page 1 of this referral is for entering youth demographics, basic referral information, and worker's contact information.
  • Page 2 of this referral is for providing parents names and dates of birth and any available information you have regarding other relative or kin. We are unable to begin relative/kin search and engagement services without the required fields on page 2 being completed.
  • Page 3 of this referral is for you to review all previously entered information, revise as needed, and submit the referral.

Thank you in advance for all the information you're providing. This will greatly assist us in our relative search & engagement efforts for the youth!

Basic Information & Youth 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)* *
ICWA | Tribal Membership  
Tribal Affiliation  
Referral Information
Who is Making Referral?*  
Has there been a TPR?*
Approximate Date of Most Recent TPR* *Calendar
Has this youth been previously adopted? (finalized)*
Approximate Date of Last Kinship Search: Calendar
County Information
Enter information for the county worker responsible for making decisions and signing legal paperwork for the youth.
County of Responsibility*  
Assigned County Worker First and Last Name*
Assigned County Worker Role with Youth*
Assigned County Worker Phone Number*
()-ext
Enter Int'l Number
Assigned County Worker Phone Number Type* * 
Assigned County Worker Email*
Assigned County Worker Fax Number
()-ext
Enter Int'l Number
List Other County Workers Involved with Case*
List other county workers involved in case (Include Name, Phone, Email, and Role with Youth). If there are no other workers, write none in the box.
Child Specific Recruitment Information
If youth is currently receiving child specific recruitment services from a PPAI agency, please enter information for the assigned recruiter and their agency.
Is Youth Currently Receiving Child Specific Services from a PPAI Agency?*  
Child Specific Recruiter First and Last Name* *
Child Specific Recruiter Phone Number
()-ext
Enter Int'l Number
Child Specific Recruiter Phone Number Type* * 
Child Specific Recruiter Email* *
Child Specific Recruiter Agency* * 
Sibling Group Information
If there are multiple siblings being referred together, please enter Yes for Sibling Group and each siblings First and Last Name & Date of Birth in the Sibling Details field.

If
not, please select No for Sibling Group indicating to Ampersand Families the referral is for one youth regardless if the youth has siblings.
Sibling Group*
Head of Case for Sibling Group* * 
Select Yes if primary youth being referred (i.e., youth listed above) is the oldest sibling in the group. Otherwise, select no.
Has there been a legal sibling separation?* * 
Select Yes if a court has issued a legal sibling separation. Otherwise, select No.
Sibling Details* *
Notes regarding siblings (placed together y/n and other things we should know)* *
Other Notes
Please enter any additional information you think we need to know that would be helpful.
Other Notes
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