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Youth Referral Form

Basic Information & Demographics
Referral Type  
Child First Name*
Child Middle Name
Child Last Name*
Child Birth Date* Calendar
Sexual Orientation  
Child Race/Ethnicity
ICWA | Tribal Membership  
Referral Information
Please Note: PPAI Contract requires that every youth referred for Child Specific Recruitment be under guardianship of the Commissioner or a Tribe and that the youth be registered on the State Adoption Exchange prior to referral.
County of Responsibility*  
Has there been a TPR?
Most Recent TPR Date Calendar
Has this youth been previously adopted? (finalized)
Approximate Date of Last Kinship Search: Calendar
What has been challenging finding an adoptive family for this youth?
Is Youth currently on probation?
Please share anything about the youth's personality, interests or unique needs that might help us decide which Permanency Specialist or Photographer might be the best fit
Sibling Group
Sibling Group
Please provide Name, Birth Date and Current City for each child in the sibling group
Notes regarding referral (placed together y/n and other things we should know)
Information about Current Placement
Current Location Name
Current Location Type  
Date Youth Arrived at Current Location Calendar
Current Location Contact Person
Current Location Street Address
Current Location Address 2
Current Location City*
Current Location State
Enter Region
Current Location Zip Code
Current Location Phone Number
Enter Int'l Number
Referring County Worker
Referring Worker Name*
Referring Worker Role
Referring Worker Address 1:
Referring Worker Address 2:
Referring Worker City:
Referring Worker State:
Enter Region
Referring Worker Zip:
Referring Worker Phone:
Enter Int'l Number
Referring Worker Phone 2:
Enter Int'l Number
Referring Worker Email:*
List other county workers or private agency recruiters involved in case
Include Name, phone, email, and role.
Guardian Ad Litem - Skip for Heart Gallery Referral
Does the youth have a guardian ad litem?
GAL Name
GAL Address 1:
GAL Address 2:
GAL City:
GAL State:
Enter Region
GAL Zip:
GAL Phone:
Enter Int'l Number
GAL Phone 2:
Enter Int'l Number
GAL Email:
Lawyer - Skip for Heart Gallery Referral
Child does not have a lawyer:
Lawyer Name:
Lawyer Address:
Lawyer Address 2:
Lawyer City:
Lawyer State:
Enter Region
Lawyer Zip:
Lawyer Phone:
Enter Int'l Number
Lawyer Phone 2:
Enter Int'l Number
Lawyer Email:
Recruitment Efforts - In the past 12 months has the youth...
Been on Kid Connection/Thursday's Child?
Been presented at the state wide adoption task force?
Had other special media coverage or recruitment opportunities?
Had information on the State Adoption Exchange posted/updated?
Had photo on the State Adoption Exchange posted/updated?
Had Heart Gallery photo taken?
Heart Gallery referral - Please Complete
Please provide the name of any Child Specific Recruiter assigned to the case. Confirm that this is the person who should be contacted to coordinate the photo shoot.
Relative/Kin Home Study - Please Complete
Relative or Kin Name, DOB, Address, Phone and Social Security Number
Please provide basic information for each person or couple to be studied. Within a few days we will send you a link to submit more detailed information regarding the person/s to be home studied.
What is this Relative/Kin's Relationship to Youth?
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