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

Our PPPC 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. Please make sure to click save at bottom of form.

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!

Referral Information

Who is Making Referral?*

Has there been a TPR?*

Yes

Approximate Date of Most Recent TPR**

Has this youth been previously adopted? (finalized)*

Yes

Has a Kinship Search been Completed?*

Approximate Date of Last Kinship Search:**

Most Recent Kinship Search Report

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*

Enter International

Assigned County Worker Phone Number Type**

Assigned County Worker Email*

Assigned County Worker Fax Number

Enter International

List Other County Workers Involved with Case *

Child Specific Recruitment Information

If youth is currently receiving child specific recruitment services from a PPPC agency, please enter information for the assigned recruiter and their agency.

Is Youth Currently Receiving Child Specific Recruitment Services from a PPPC Agency? *

Child Specific Recruiter First and Last Name**

Child Specific Recruiter Phone Number

Enter International

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*

Yes

Head of Case for Sibling Group **

Has there been a legal sibling separation? **

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

Save