Child-Specific Recruitment Services Child-Specific Recruitment Referral We appreciate your time in helping us gather information regarding the youth! Step 1 of 10 10% Youth InformationName First Middle Last PronounsGenderFemaleMaleSexMaleFemaleInter-sexDate of Birth MM slash DD slash YYYY Race(s)Number of SiblingsAre Siblings Being Placed Together?YesNoNote: A separate referral form will need to be completed for each siblingIf no, is there a court ordered sibling separation?YesNoNote: We are unable to recruit for youth separate from siblings if there has not been a court-ordered separation.Does ICWA Apply?YesNo Referring Social Worker's InformationRoleAgencyName First Last Email Phone Other Workers InvolvedRoleAgencyAgencyName First Last Email PhoneRoleAgencyName First Last Email PhoneRoleAgencyName First Last Email Phone Youth's Current Living SituationCurrent Living SituationRelative/Kin Foster HomeNon-Relative Foster HomeGroup HomeResidential Treatment FacilityCorrectionsOtherIf 'Other' - Please DescribeName of Foster Parents or Staff ContactName of Foster Parent(s), Supervision Agency or FacilityAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country PhoneEmail School InformationName of SchoolGradeContact PersonPhoneEmail Is there an IEP?YesNo Placement HistoryDate of 1st Out-of-Home Placement MM slash DD slash YYYY Reason for Initial PlacementBeginning Date of Current Continuous Out-of-Home Placement MM slash DD slash YYYY When Did Youth Move Into Most Current Placement? MM slash DD slash YYYY Has youth experienced an adoption disruption (prior to finalization)?YesNoIf yes, how many?Has youth experienced an adoption dissolution (after finalization)?YesNoIf yes, how many?Termination of Parental RightsParent 1 First Last Parent 1 TPR Date MM slash DD slash YYYY Parent 2 First Last Parent 2 TPR Date MM slash DD slash YYYY Assessment & Diagnosis InformationMAPCY Level (from most recent assessment)Please List Any Of The Following (if applicable):Mental Health Diagnoses Add RemovePhysical Disabilities Add RemoveCorrections History Add RemoveAdditional Information Birth Family InformationDoes Youth Have Contact With Siblings Placed Separately?YesNoDoes Youth Have Known Contact With Either Birth Parent?YesNoIf yes to either question above - please describe the type, frequency & quality of contact between the youth & birth family members:Are Birth Parent Whereabouts Known?YesNo Recruitment ServicesPlease Share the Top 3 Reasons It Has Been Challenging to Find a Family For This Youth: Add RemoveWhat Was the Youth's Reaction to Participating in Child-Specific Recruitment?What Was the Reaction of the Foster Parent/Care Provider Regarding the Youth's Involvement in Child Specific Recruitment?Please Provide Any Information On Previous Recruitment Efforts (check all that apply): Registered on SAE (if yes, indicate date below) Presented at Task Force Kid Connection Media Child Specific Recruitment w/ another agency Adoption Recruitment/Matching Event Other (if yes, indicate date below) Date Registered on SAE: MM slash DD slash YYYY Other Recruitment Effort(s):Does The Youth Have a Lifebook Completed or Partially Completed?YesNoIf So, By Whom? Please Attach a Copy of the FollowingTermination of Parental RightsMax. file size: 50 MB.Updated Social/Medical HistoryMax. file size: 50 MB.Out-of-Home Placement PlanMax. file size: 50 MB.Referral PacketMax. file size: 50 MB.I verify that, at a minimum, the following activities have been completed and that this/these youth are therefore eligible to receive child-specific recruitment services under the Public Private Adoption Initiative Contract. (1) A relative/kinship search according to the policies & procedures as required by statute. (2) The child or sibling group has been registered on the State Adoption Exchange (SAE).If these have not been completed, please contact us to discuss when they can occur ([email protected] | 651.255.2275)Your Name First Last Your Role/Relationship to the YouthCAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
