CSR Referral Form

CSR Referral Form

Referral Information
Referral Type*  
Responsible County/Agency*  
Is this referral for an individual youth or sibling group*  
Has there been a TPR?*
TPR Dates and Information*
Please include all known TPR dates for this child
Approximate Date of Last Kinship Search* Calendar
Have there been previous CSR services completed in the past?*
If yes, please provide additional information about the previous CSR services:* *
Date Placed on State Adoption Exchange* Calendar
Has this youth been previously adopted?*
Please discuss your challenges in finding an adoptive family for this youth*
Please share anything about the youth's personality, interests or unique needs that would be helpful for us to know
Youth Information
**For sibling group referrals, please use the oldest child to fill out the fields below.** 
Child First Name*
Child Middle Name*
Child Last Name*
Child Birth Date* Calendar
Child Race
 
Language  
Gender  
Sexual Orientation  
Tribal Affiliation
Currently on Probation or Parole*
Current Location Type*  
Date Youth Arrived at Current Location* Calendar
Current Location Contact Person*
Current Location Address*
Current Location Phone Number*
()-ext
Enter Int'l Number
Please provide the Name, DOB and Location for all additional siblings in this referral* *
Additional notes on the sibling referral
Add in information about whether or not they are currently placed together along with any other pertinent information about the sibling group.
Youth Information cont.
Strengths of the Child/ren*
Child/ren History*
Services Needed While in Care*
Recent DA or Psychological Evaluation*
DA/Psych Eval Information* *
History of Self-Harm or Suicidal Ideations/Attempts*
Self-Harm Information* *
Medical Concerns/Disabilities*
Medical Concerns Information* *
Youth Details
History of fire setting*
Cruelty to animals*
Risk to other children*
Physically aggressive*
Victim of physical abuse*
Victim of sexual abuse*
Sexually acting out behaviors*
Drug/alcohol use*
Tobacco use*
Run risk*
Destructive to property*
Dietary concerns*
Additional Notes on Youth Details* *
If you answered "Yes" for any of the questions above, please explain in this box.
Referring Worker Information
Worker Name*
Worker Role*
Worker Full Address*
Worker Phone Number*
()-ext
Enter Int'l Number
Worker Email*
List of Other Workers/Recruiters Involved:*
Please include contact information as well, if known. If no other workers involved, please indicate in this box.
Guardian Ad Litem
Does the youth have a Guardian Ad Litem?*
GAL Name* *
GAL Full Address* *
GAL Phone Number*
()-ext
*Enter Int'l Number
GAL Email* *
Recruitment Efforts- In the past 12 months, has the youth....
Been on Kid Connection/Thursday's Child?*
Been presented at the statewide 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 photos taken?*
Lifebooks
**Our agency will create Lifebooks for each child receiving recruitment services.  The NHCFS Recruiter will engage in activities with the child to create a Lifebook that best reflects their story from birth to present.  Our agency strives to tell each child's story truthfully, but in a way that is developmentally appropriate.  In order to gather information, we may need your assistance in the following areas:

 
No Contact List
Please list any persons who you would NOT like to be contacted for Lifebook purposes. Please include their name and relationship. All people should be added by entering them on their own line.
Significant People who MAY be Contacted
Please enter each person on their own line and include their: (Name, Relationship, Phone, Address and Email)
Schools the Child Has Attended
Please enter each school on its own line and include: (School Name, Significant Contact Person, City, Grades Attended)
Lifebook Information
 
**Our agency typically contacts the following sources to obtain information about Lifebooks.  Examples of the materials we request are listed under each section**

> Previous foster home/group home/residential center/day care/respite provider/mentors
  • Photo of the foster family
  • Photo of the home/facility and staff
  • Photos of the children while in placement at each location
  • Letters of encouragement and support to the child
  • Possible memorabilia and artwork
> Birth Family (birth parents, grandparents, aunts, uncles, siblings, etc)
  • Photos of themselves, other relatives, siblings, pets, etc
  • Photos of the children from birth to present
  • A letter to the child sharing their thoughts and memories of the child (as deemed appropriate)
  • Any memorabilia, artwork, baby items, etc
> Schools
  • Yearbook pictures
  • Report cards
  • Photo of the school
  • Photos of teachers
  • Letter or memories from personnel
> Hospitals
  • Photo of the hospital
  • Possible photo of the delivering doctor
> Guardian ad Litem/Social Worker
  • Photo of themselves
  • A letter to the child from GAL/SW
  • Photos of the child
  • Any additional information
 
  
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North Homes Children & Family Services | Toll Free (888) 430-3055 | www.northhomesinc.org