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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
Gender  
Sexual Orientation  
Child Race/Ethnicity
 
ICWA | Tribal Membership  
Language
 
Referral Information
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?
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 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 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:
()-ext
Enter Int'l Number
Referring Worker Phone 2:
()-ext
Enter Int'l Number
Referring Worker Email:
List other county workers involved in case
Include Name, phone, email, and role.
Guardian Ad Litem
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
Child does not 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?
For Heart Gallery Referrals Only
If this is a Heart Gallery Referral, 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.
Please share any information about the youth to best help match the youth with a photographer (i.e. location, interests, special needs etc.):
 
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Ampersand Families | 2515 Wabash Ave., Suite 150 | St. Paul, MN 55114 | Office: 612.605.1904