Referral Form - Growing Kinship Connection

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Growing Kinship Connection: Referral Form

This form is designed to refer a child to the Growing Kinship Connection (GKC) program. The GKC program aims to educate and help Kin Caregivers, Fathers, and non-biological relatives navigate the Child Protection and Welfare system in St. Louis County, Minnesota.

Referral Source

This section allows you to select the type of referral

Referred by?

Community Provider

County Social Worker

Self-Referral

Other

Community Provider Information

This section will capture the basic information of the Community provider referring this case.

Community Provider's First & Last name

First Last

Community Provider's Phone Number

Community Provider's Email Address

Any Other Information We Should Know About?

Would You Like To Provide Social Worker's Information?

Yes

Self-Referral

This section will capture any additional information that might not have been captured before.

Are You The Father/Mother?

Yes

You will provide your information in a later section.

Are You A Kin?

Yes

Kin Status?

Other

Kin's Name

First Last

Kin's Phone

Kin's Email

Kin's Address

Street Address Address Line 2 City State ZIP Code

Your Name

First Last

Your Phone

Your Email

Your Address

Street Address City State ZIP Code

Any Other Information We Should Know About?

Would You Like To Provide Social Worker's Information?

Yes

Social Worker Information

This section will capture the basic information of the social worker(s) working on this case.

Social Worker's First & Last Name

First Last

Social Worker's Phone Number

Social Worker's Email Address

Select The Referring Unit From The List Below

Other

Provide Any Additional Details We Should Be Aware Off

List the Name & Contact Detail of Any Other Social Worker Who Has Worked on This Case

Kin CareGiver Placement Information

This section will capture Kin's information with whom the child's placed.

Kin Caregiver's First & Last Name

First Last

Kin Caregiver's Physical Address

Street Address City State / Province / Region ZIP / Postal Code

Kin Caregiver's Phone Number

Kin Caregiver's Email Address

Kin Caregiver's Date of Birth

Are You A ...?

Other

Kin Caregiver's Employment Information

Kin Caregiver's Emergency Contact

Foster Parent(s) Information

Foster Parent 1 Name

First Last

Foster Parent 2 Name

First Last

Foster Parent's Physical Address

Street Address City State / Province / Region ZIP / Postal Code

Foster Parent's Phone Number

Foster Parent's Employment Information

Foster Parent's Emergency Contact

Parent's Information

Capture Father & Mother's information

Would You Like to Add Mother's Information?

Yes

Mother's Information

This section will capture the Mother's information.

Mother's First & Last Name

First Last

Mother's Physical Address

Street Address City State / Province / Region ZIP / Postal Code

Mother's Phone Number

Mother's Email Address

Mother's Employment Information

Mother's Emergency Contact

How Many Children Are In The Household?

Provide the Names (First, Last, Date of Birth) of Other Children In The Household (If Applicable)

Mother's Service Providers

Other

Please provide Name & Contact Information for Service Providers.

Mother Has Stable Housing?

Yes

Additional Details

Homeless/Homelessness

Couch Surfing

Other

Any Other Information We Should Know About?

Would You Like to Add Information About Other Partners of the Mother? (Optional)

Do You Have the Father's Information to Add?

Yes

Father's Information

This section will capture the Father's information.

Father's First & Last Name

First Last

Father's Physical Address

Street Address City State / Province / Region ZIP / Postal Code

Father's Phone Number

Father's Email Address

Father's Employment Information

Father's Emergency Contact

Father's Service Providers

Other

Please provide Name & Contact Information for Service Providers.

Father Has Stable Housing?

Yes

Additional Details

Homeless/Homelessness

Couch Surfing

Other

Any Other Information We Should Know About?

Would You Like to Add Information About Other Partners of the Father? (Optional)

Provide Additional Details?

Where did you hear about us?

Please Add Any Additional Documents Available For This Case?

Drop files here or

Accepted file types: doc, docx, pdf, jpg, png, Max. file size: 100 MB.

This field is for validation purposes and should be left unchanged.

Growing Kinship Connection: Referral Form

Referral Source

Community Provider Information

Self-Referral

Social Worker Information

Child's Bio

Child's Placement Information

Kin CareGiver Placement Information

Foster Parent(s) Information

Parent's Information

Mother's Information

Father's Information

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