Relative Referral

Relative/Kinship Referral

North Homes Children and Family Services (NHCFS) would like to thank you for your relative/kinship referral. We look forward to working with you during this process and ask that you be as thorough as possible when completing the online referral form.

NHCFS understands that every referral will be unique and our staff will work with your county and/or tribal agency to obtain relevant information regarding the specific details of the case. Once NHCFS receives the referral, our staff will contact the family to explain the home study assessment/licensing process.

Relative/Kinship provider orientation and interviews will be conducted with the family at the same time that all other requirements are being gathered, which includes personal references, background studies, home safety checklist, and training that is relevant to the needs and ages of the child or sibling group.

On average, the home study assessment/licensing process takes three to four months; however, this may vary case-by-case, depending on how quickly the requirements are completed by the applicant(s). NHCFS will keep the referring agency updated regarding the family’s progress and will inform them if any concerns arise. Once the home study assessment is completed, it will be reviewed with the family and a copy will be sent to the referring agency.

PPAI grant funding may be available through the Minnesota Department of Human Services (DHS). Upon receipt of this referral, NHCFS will screen the information to determine if it meets grant eligibility.

County/Tribal Agency Information

Date of Referral:*

County/Tribe:*

Referring Worker's Name:*

Worker Phone Number:*

Enter International

Worker Email:*

Family Information

This section is for Family information only. Please enter only one applicant in the name fields below. Then use the box at the bottom to list the other applicant(s) and any other information you would like to add about the family.

First Name*

Last Name*

Cell Phone Number *

Enter International

Street Address*

City*

State/Region*

Enter Region

Zip Code*

Additional Information

Referral Information

1. What is the relationship between the individual(s) and the child or sibling group?*

2. Does the child or sibling group know that the individual(s) may be a potential permanency option?*

Yes

3. Has information about the child or sibling group been provided to the individual(s) regarding why they are in an out-of-home placement?*

Yes

If yes to Question #3, please explain:**

4. Does the child or sibling group have current contact with the individual(s)?*

Yes

If yes to Question #4, please explain:**

Home Study/Licensing Information

5. Are there specific areas or concerns that need to be addressed during the home study process?*

Yes

If yes to Question #5, please explain:**

6. Please describe any deadlines or concerns about the timing of this relative home study:*

7. Would you like NHCFS to license this home for child foster care?*

Yes

8. If the individual(s) obtains an approved home study and is licensed for child foster care, is the treatment team in support of utilizing them as a placement/permanency option?*

Yes

If yes to Question #8, please explain:**

9. Are there any other individuals that are interested in being a permanency option?*

Yes

If yes to Question #9, please list their names and describe their relationship with the child or sibling group:**

Child Information

10. Please list the children's names and DOBs involved in this referral: *

11. Has TPR/SPR occurred?*

Yes

If yes to Question #11, please provide NHCFS with a copy. If no, please explain:**

12. Is it anticipated that this will be an adoption or a transfer of permanent legal and physical custody (TPLPC)?*

Adoption

TPLPC

Please explain:*

13. Please list the name(s) and contact information for any other treatment team members who might have additional information with regard to this referral: *

14. Will the out-of-home placement plan(s) and other pertinent information be shared with NHCFS?*

Yes

15. Where does the child or sibling group currently reside and how long have they been there:*

PPAI Information for Billing Purposes

Relative Home Study and Relative Home Study Update Services: Contracted agency must assess the relative/kin's ability to parent a specific child or children under state or tribal guardianship, or a child in out-of-home care referred by a county or tribal social service agency for a concurrent planning resource home study, and complete a summary using the commissioner's designated format. Contracted agency will also assist the county or tribal social service agency, if requested, with establishing appropriate contact plans between the identified child(ren) and identified relative or kin, if a decision to not place with a client is made.

1. Is the child or sibling group currently under state or tribal guardianship?*

Yes

2. If not, is the county/tribe requesting an assessment of the identified family for the purpose of concurrent permanency planning?*

Yes

3. If the assessment is for concurrent permanency planning services, is the child under the age of 8 and NOT part of a sibling group?*

Yes

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