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
ICWA & Tribal Affiliation
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.
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.    
Recruitment Efforts - In the past 12 months has the youth...
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.
Information about Current Placement
Enter Region
Referring County Worker
Enter Region
Guardian Ad Litem
Enter Region
Lawyer
Enter Region
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.