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Child Specific Recruitment Referral Form

Basic Information & Demographics
First Name*
Middle Name
Last Name*
Birthdate* Calendar
Gender*  
Pronouns Youth Uses
 
Pronouns Other (If other or multiple pronouns, please type in desired pronouns)* *
Sexual Orientation  
Race/Ethnicity (please select all that apply)
 
Race/Ethnicity Other (If 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?*
Approximate Date of Most Recent TPR* *Calendar
Has this youth been previously adopted? (finalized)*
Approximate Date of Last Kinship Search: Calendar
Please share name and contact information for anyone (relative/kin/other) you know of who might be a permanency or support resource*
For each permanency resource, please provide their first & last name, relationship to youth, & contact information.
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
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?*
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*
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 Calendar
Current Location Contact Person*
Current Location Phone Number*
()-ext
Enter Int'l Number
Current Location Street Address
Bldg./Apt. #
Current Location City*
Current Location State
Enter Region
Current Location Zip Code
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
Work Cell Phone Number
()-ext
Enter Int'l Number
Email*
Fax Number
()-ext
Enter Int'l Number
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.*
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. If youth doesn't have any other workers, indicate by putting "none" in the box.
Youth's Current Service Providers*
For each service provider, please list their first and last name, organization, relationship to the youth, and contact information.
Guardian Ad Litem
Does the youth have a guardian ad litem?*
GAL Name* *
GAL Street Address:
GAL Bldg./Suite #:
GAL City:
GAL State:
Enter Region
GAL Zip:
GAL Phone:
()-ext
Enter Int'l Number
GAL Work Cell Phone
()-ext
Enter Int'l Number
GAL Email:
Lawyer
Does the child have a lawyer?*
Lawyer First & Last Name:* *
Lawyer Address:
Lawyer Bldg./Suite #:
Lawyer City:
Lawyer State:
Enter Region
Lawyer Zip:
Lawyer Work Phone:
()-ext
Enter Int'l Number
Lawyer Cell Phone:
()-ext
Enter Int'l Number
Lawyer Email:
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Ampersand Families | 1751 County Road B West, Suite 300 | Roseville, MN 55113 | Office: 612.605.1904