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Youth Referral Form

Basic Information & Demographics
Referral Type*  
First Name*
Middle Name
Last Name*
Birthdate* Calendar
Gender*  
Sexual Orientation  
Race/Ethnicity (please select all that apply)
 
Race/Ethnicity Other (please type in race/ethnicity)* *
ICWA | Tribal Membership  
Language (please select all that apply)
 
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 Youth Previously Received Recruitment Services
Were Previously Received Recruitment Services Provided by Ampersand Families
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 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
()-ext
Enter Int'l Number
Referring County Worker
First & Last Name*
Role with Youth
Street Address
Building/Suite #
City
State
Enter Region
Zip Code
Work Phone Number
()-ext
Enter Int'l Number
Referring Worker Phone 2:
()-ext
Enter Int'l Number
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:
()-ext
Enter Int'l Number
GAL Phone 2:
()-ext
Enter Int'l Number
GAL Email:
Lawyer - Skip for Heart Gallery Referral
Does the child have a lawyer?
Lawyer Name:* *
Lawyer Address:
Lawyer Address 2:
Lawyer City:
Lawyer State:
Enter Region
Lawyer Zip:
Lawyer Phone:
()-ext
Enter Int'l Number
Lawyer Phone 2:
()-ext
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 Only
Child Specific Recruiter
Person who will be assisting with scheduling the photo session.
Child Specific Recruiter Email
Assigned County Worker
Assigned County Worker Email
Can Youth Photos be Placed on Public Facing Websites
Please share anything about the youth's personality, interests or unique needs that will help us decide which Photographer might be the best fit
Notes
Relative/Kin Home Study Only
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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