Child Specific Recruitment Referral Form
Please Note:
Our PPAI Contract with DHS requires every youth referred for Child Specific Recruitment:
Be under guardianship of the Commissioner or a Tribe
and
Be registered on the State Adoption Exchange (SAE) prior to referral.
If the youth has been separated from their sibling/s, we need a copy of the court order.
Please submit the referral
after
there has been a Termination of Parental Rights (TPR)
and
the Youth has been registered on the SAE and if applicable, a court has legally approved the sibling separation.
Basic Information & Demographics
First Name
*
Middle Name
Last Name
*
Preferred Name
Birthdate
*
Gender
*
Female
Male
Non-binary/Genderfluid/Gender Queer
Questioning
Transgender/FtM/Assigned Female at Birth
Transgender/MtF/Assigned Male at Birth
Other
Client doesn't know
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)
**
Sexual Orientation
Questioning
Bisexual/Pansexual
Gay/Lesbian
Straight/Heterosexual
Not Disclosed - Youth Too Young
Other
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)
**
Language (please select all that apply)
English
Somali
Spanish
Hmong
Other
Language Other (If other, please enter the language/s)
**
ICWA & Tribal Affiliation
ICWA Applies?
*
Yes
No
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
**
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.
Would you also like to make a referral for Relative Search & Engagement Services?
*
Need more Information
Yes
No
County of Responsibility
*
Aitkin
Anoka
Becker
Beltrami
Benton
Big Stone
Blue Earth
Brown
Carlton
Carver
Cass
Chippewa
Chisago
Clay
Clearwater
Cook
Cottonwood
Crow Wing
Dakota
Dodge
Douglas
Faribault
Fillmore
Freeborn
Goodhue
Grant
Hennepin
Houston
Hubbard
Isanti
Itasca
Jackson
Kanabec
Kandiyohi
Kittson
Koochiching
Lac qui Parle
Lake
Lake of the Woods
Le Sueur
Lincoln
Lincoln, Lyon Murray
Lyon
Mahnomen
Marshall
Martin
McLeod
Meeker
Mille Lacs
Morrison
Mower
Murray
Nicollet
Nobles
Norman
Olmsted
Otter Tail
Out-of-State County
Pennington
Pine
Pipestone
Polk
Pope
Ramsey
Red Lake
Redwood
Renville
Rice
Rock
Roseau
Scott
Sherburne
Sibley
St Louis
Stearns
Steele
Stevens
Swift
Todd
Traverse
Wabasha
Wadena
Waseca
Washington
Watonwan
Wilkin
Winona
Wright
Yellow Medicine
Has Youth Previously Received Recruitment Services
*
Yes
No
Were Previously Received Recruitment Services Provided by Ampersand Families
**
Yes
No
Has there been a TPR?
*
Yes
No
Approximate Date of Most Recent TPR
**
Has this youth been previously adopted? (finalized)
*
Yes
No
Approximate Date of Last Kinship Search:
Please share name and contact information for anyone (relative/kin/other) you know of who might be a permanency or support resource
*
What has been challenging finding an adoptive family for this youth?
*
Is Youth currently on probation?
*
Yes
No
Additional Referral Information
Our youth workers hold a variety of different identities (racial, gender identity and sexual orientation, lived experience, etc.) to help serve and represent the youth we work with. Responses to these questions will not affect our accepting a youth referral, they will assist in matching youth with a permanency specialist.
Please share any additional characteristics about the youth that would be helpful in matching them with a permanency specialist such as youth’s personality, interests, unique needs?
*
In the past or present, has youth shared any biases toward any race, gender identity, sexual orientation, etc. that would impact their ability to work with someone in named identity group?
*
Please share any concerns you may have regarding any adults in the youth’s life (foster parents, social workers, guardians ad litem, relatives, etc.) regarding work with any above mentioned identities.
*
Recruitment Efforts - In the past 12 months has the youth...
Been on Kid Connection/Thursday's Child?
*
Yes
No
Been presented at the state wide adoption task force?
*
Yes
No
Had other special media coverage or recruitment opportunities?
*
Yes
No
Had information on the State Adoption Exchange posted/updated?
*
Yes
No
Had photo on the State Adoption Exchange posted/updated?
*
Yes
No
Had Heart Gallery photo taken?
*
Yes
No
Sibling Group
If referring a sibling group, please provide First & Last Name, Birth Date, & Current City for each child in the sibling group in the Sibling Details field.
Sibling Group
*
Yes
No
Has there been a legal sibling separation?
**
No
Yes
Please Upload Copy of Sibling Separation Court Order if available
Document Uploaded
Reupload
Sibling Details
**
Notes regarding siblings (placed together y/n and other things we should know)
**
Information about Current Placement
Current Location Name (e.g., name of foster parent/s or place youth is staying with/at)
*
Current Location Type
*
Adoptive Home
Adoptive Relative's Home
Biological Parent's Home
Biological Relative's Home
Concurrent Planning
Detention or other Correctional Facility
Extended Foster Care/IL
Foster Home - Kin
Foster Home - MITH
Foster Home - Non Kin
Group Home
Homeless/Couch Hopping
Hospital
Living Independently
Pre-Adopt Home
Residential Treatment
Respite
Shelter
Date Youth Arrived at Current Location
*
Current Location Contact Person
*
Current Location Phone Number
*
Enter International
Email
Current Location Street Address
Bldg./Apt. #
Current Location City
*
Current Location State
Select US-State
AK - Alaska
AL - Alabama
AR - Arkansas
AS - American Samoa
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
FM - Federated States of Micronesia
GA - Georgia
GU - Guam
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MH - Marshall Islands
MI - Michigan
MN - Minnesota
MO - Missouri
MP - Northern Mariana Islands
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
PW - Palau
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VI - Virgin Islands
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Enter Region
Current Location Zip Code
Referring County Worker
First & Last Name of Person Making Referral
*
Referring Worker Role with Youth
*
Street Address
Building/Suite #
City
State
Select US-State
AK - Alaska
AL - Alabama
AR - Arkansas
AS - American Samoa
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
FM - Federated States of Micronesia
GA - Georgia
GU - Guam
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MH - Marshall Islands
MI - Michigan
MN - Minnesota
MO - Missouri
MP - Northern Mariana Islands
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
PW - Palau
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VI - Virgin Islands
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Enter Region
Zip Code
Office Phone Number
*
Enter International
Work Cell Phone Number
Enter International
Email
*
Fax Number
Enter International
Guardian Ad Litem
Does the youth have a guardian ad litem?
*
Yes
No
GAL Name
**
GAL Street Address:
GAL Bldg./Suite #:
GAL City:
GAL State:
Select US-State
AK - Alaska
AL - Alabama
AR - Arkansas
AS - American Samoa
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
FM - Federated States of Micronesia
GA - Georgia
GU - Guam
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MH - Marshall Islands
MI - Michigan
MN - Minnesota
MO - Missouri
MP - Northern Mariana Islands
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
PW - Palau
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VI - Virgin Islands
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Enter Region
GAL Zip:
GAL Phone:
Enter International
GAL Work Cell Phone
Enter International
GAL Email:
Lawyer
Does the child have a lawyer?
*
Yes
No
Lawyer First & Last Name:
**
Lawyer Address:
Lawyer Bldg./Suite #:
Lawyer City:
Lawyer State:
Select US-State
AK - Alaska
AL - Alabama
AR - Arkansas
AS - American Samoa
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
FM - Federated States of Micronesia
GA - Georgia
GU - Guam
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MH - Marshall Islands
MI - Michigan
MN - Minnesota
MO - Missouri
MP - Northern Mariana Islands
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
PW - Palau
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VI - Virgin Islands
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Enter Region
Lawyer Zip:
Lawyer Work Phone:
Enter International
Lawyer Cell Phone:
Enter International
Lawyer Email:
Additional 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.
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.
*
Youth's Current Service Providers
*
Submit