CSR Referral Form
CSR Referral Form
Referral Information
Referral Type
*
Adoption/TPR
CSR
Delinquency
Foster Care
TPLPC
Pre-Adoption/Concurrent
Respite
Voluntary
Responsible County/Agency
*
Aitkin
Anoka
Becker
Beltrami
Benton
Big Stone
Blue Earth
Brown
Carlton
Carver
Cass
Chippewa
Chisago
Clay
Clearwater
Cook
Cottonwood
Crow Wing
Dakota
Dodge
Douglas
Faribault
Fillmore
Freeborn
Goodhue
Grant
Hennepin
Houston
Hubbard
Isanti
Itasca
Jackson
Kanabec
Kandiyohi
Kittson
Koochiching
Lac qui Parle
Lake
Lake of the Woods
Le Sueur
Lincoln
Lyon
Mahnomen
Marshall
Martin
McLeod
Meeker
Mille Lacs
Morrison
Mower
Murray
Nicollet
Nobles
Norman
Olmsted
Otter Tail
Pennington
Pine
Pipestone
Polk
Pope
Ramsey
Red Lake
Redwood
Renville
Rice
Rock
Roseau
Scott
Sherburne
Sibley
St. Louis
Stearns
Steele
Stevens
Swift
Todd
Traverse
Wabasha
Wadena
Waseca
Washington
Watonwan
Wilkin
Winona
Wright
Yellow Medicine
Is this referral for an individual youth or sibling group
*
Individual
Sibling Group
Has there been a TPR?
*
Yes
No
TPR Dates and Information
*
Approximate Date of Last Kinship Search
*
Have there been previous CSR services completed in the past?
*
Yes
No
If yes, please provide additional information about the previous CSR services:
**
Date Placed on State Adoption Exchange
*
Has this youth been previously adopted?
*
Yes
No
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
*
Child Race
White/Caucasian
American Indian/Alaska Native
Black/African American
Asian
Hispanic/Latino
Native Hawaiian/Pacific Islander
Multiracial/Other
No Preference
Unknown
Language
English
Spanish
Chinese
French
German
Italian
Japanese
Korean
Portuguese
Russian
Other
Gender
Male
Female
Questioning
Transgender- Male to Female
Transgender-Female to Male
Other
Sexual Orientation
Heterosexual
Gay/Lesbian
Bisexual
Other
Undisclosed
Tribal Affiliation
Currently on Probation or Parole
*
Yes
No
Current Location Type
*
Birth Father
Birth Mother
Detention
Emergency Shelter
Foster Family
Group Home
Hospital/Clinic
No prior placements
Organization
Relative
Respite
Treatment Facility
Unknown
Date Youth Arrived at Current Location
*
Current Location Contact Person
*
Current Location Address
*
Current Location Phone Number
*
Enter International
Please provide the Name, DOB and Location for all additional siblings in this referral
**
Additional notes on the sibling referral
Youth Information cont.
Strengths of the Child/ren
*
Child/ren History
*
Services Needed While in Care
*
Recent DA or Psychological Evaluation
*
Yes
No
DA/Psych Eval Information
**
History of Self-Harm or Suicidal Ideations/Attempts
*
Yes
No
Self-Harm Information
**
Medical Concerns/Disabilities
*
Yes
No
Medical Concerns Information
**
Youth Details
History of fire setting
*
Yes
No
Cruelty to animals
*
Yes
No
Risk to other children
*
Yes
No
Physically aggressive
*
Yes
No
Victim of physical abuse
*
Yes
No
Victim of sexual abuse
*
Yes
No
Sexually acting out behaviors
*
Yes
No
Drug/alcohol use
*
Yes
No
Tobacco use
*
Yes
No
Run risk
*
Yes
No
Destructive to property
*
Yes
No
Dietary concerns
*
Yes
No
Additional Notes on Youth Details
**
Referring Worker Information
Worker Name
*
Worker Role
*
Worker Full Address
*
Worker Phone Number
*
Enter International
Worker Email
*
List of Other Workers/Recruiters Involved:
*
Guardian Ad Litem
Does the youth have a Guardian Ad Litem?
*
Yes
No
GAL Name
**
GAL Full Address
**
GAL Phone Number
**
Enter International
GAL Email
**
Recruitment Efforts- In the past 12 months, has the youth....
Been on Kid Connection/Thursday's Child?
*
Yes
No
Been presented at the statewide adoption task force?
*
Yes
No
Had other special media coverage or recruitment opportunities?
*
Yes
No
Had information on the State Adoption Exchange posted/updated?
*
Yes
No
Had photo on the State Adoption Exchange posted/updated?
*
Yes
No
Had Heart Gallery photos taken?
*
Yes
No
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
Significant People who MAY be Contacted
Schools the Child Has 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
Submit
