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Family Rise Together
Referral Form
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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
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
No
Self-Referral
This section will capture any additional information that might not have been captured before.
Are You The Father/Mother?
Yes
No
You will provide your information in a later section.
Are You A Kin?
Yes
No
Kin Status?
Select One
Grandparents
Uncle/Aunt
Neighbors
Siblings
Other
Other
Kin's Name
First
Last
Kin's Phone
Kin's Email
Kin's Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Your Name
First
Last
Your Phone
Your Email
Your Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Any Other Information We Should Know About?
Would You Like To Provide Social Worker's Information?
Yes
No
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
Select One
Initial Intervention Unit (IIU) -- South
Initial Intervention Unit (IIU) -- North
Ongoing -- South
Ongoing -- North
Indian Child Welfare Act (ICWA) -- South
Indian Child Welfare Act (ICWA) -- North
Parent Support Outreach Program (PSOP) -- South
Parent Support Outreach Program (PSOP) -- North
Family Support Services (FSS) -- South
Family Support Services (FSS) -- North
Children Mental Health (CMH) North
Other
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
Child's Bio
This section will collect basic information for the child being referred.
Child's First & Last Name
First
Last
Child's Date of Birth
Month
Day
Year
Child's Gender
Male
Female
Non-Binary
Cis-Gender
Other
Child's Race
African-American/Black
American Indian
Asian/Pacific Islander
Two or More Races
Unknown/Declined
White
Is this an Indian Child Welfare Act (ICWA) Case?
Yes
No
Other
Child's Physical Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is this Child Located in St. Louis County?
Yes
No
Child's School Name
Child's Emergency Contact Name
Name
Child's Emergency Contact Phone
Child's Service Providers
Select One
Mental Health Provider
Medical Health Provider
Northwood Children and Family Services
Range Treatment Center (RTC)
Range Mental Health
HDC
Center of Alcohol and Drug (CADT)
Pediatrician
Partner in Recovery (PIR)
Lifehouse
North Homes
Safe Harbor
North Home
Other
Other
Please provide Name & Contact information for Healthcare service providers.
Please provide Name & Contact information for Social service providers.
Do You Want To Add Another Child Information For This Referral?
Yes
No
Additional Child Information
Additional Child's Name
Additional Child's Date Of Birth
Additional Child's Address
Add
Remove
Child's Placement Information
This section will capture information pertaining to the child's current placement.
Is This Child Placed With A Kin Caregiver?
Yes
No
Is This Child Placed With Foster Parents?
Yes
No
Does This Child Has Stable Housing?
Yes
No
Additional Details
Experiencing Homelessness
Couch Surfing
Runaway
Other
Other
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
Month
Day
Year
Are You A ...?
Grandmother
Grandfather
Uncle/Aunt
Father
Non-Bio relative
Other
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
No
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
Select One
Mental Health Provider
Medical Health Provider
Northwood Children and Family Services
Range Treatment Center
Range Mental Health (RMH)
HDC
Center of Alcohol and Drug (CADT)
Other
Other
Please provide Name & Contact Information for Service Providers.
Mother Has Stable Housing?
Yes
No
Additional Details
Homeless/Homelessness
Couch Surfing
Other
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
No
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
Select One
Mental Health Provider
Medical Health Provider
Northwood Children and Family Services
Range Treatment Center
Range Mental Health (RMH)
HDC
Center of Alcohol and Drug (CADT)
Other
Other
Please provide Name & Contact Information for Service Providers.
Father Has Stable Housing?
Yes
No
Additional Details
Homeless/Homelessness
Couch Surfing
Other
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
Select files
Accepted file types: doc, docx, pdf, jpg, png, Max. file size: 100 MB.
Email
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