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.

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.*

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

Has there been a legal sibling separation? **

Please Upload Copy of Sibling Separation Court Order if available

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*

Date Youth Arrived at Current Location*

Current Location Contact Person*

Current Location Phone Number*

Enter International

Current Location Street Address

Bldg./Apt. #

Current Location City*

Current Location State

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

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

GAL Name**

GAL Street Address:

GAL Bldg./Suite #:

GAL City:

GAL State:

Enter Region

GAL Zip:

GAL Phone:

Enter International

GAL Work Cell Phone

Enter International

GAL Email:

Lawyer

Does the child have a lawyer?*

Yes

Lawyer First & Last Name:**

Lawyer Address:

Lawyer Bldg./Suite #:

Lawyer City:

Lawyer State:

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