Kinship Support Referral Form

Contact Info

Contact information for the person submitting the referral

First Name *

Last Name *

Referral Date *

Local Department of Social Services Agency *

Contact Phone Number *

Email Address *

Enter Email

Confirm Email Address *

Confirm Email

Funding Start Date

Funding Stop Date

Approved Hours

FAPT Funded Child

Name *

Date of birth

Race/ Ethnicity

Current School & Grade

Religious Affiliation

Preferred Language

Current Residence *

Legal Guardian

Identified Kin Caregiver (service recipient)

Name

Age

Race/Ethnicity

Employer

Phone

Email

Religious Affiliation

Preferred Language

Relationship to Child

Current Address

Availability to Meet with Kinship Support Specialist

Additional Client Information

Reason(s) for Referral (Please check all that apply):

Child was temporarily displaced with a relative and reunification is expected within 3-6 months

Child was displaced with relative and custody is expected to transfer to relative

Prevention of kinship placement disruption

OtherOther

Is the family receiving other social services?

Mental Health Counseling/ Substance Abuse Counseling (if yes, Provider name in blank):Mental Health Counseling/ Substance Abuse Counseling (if yes, Provider name in blank):

Special Education/ Early Intervention (if yes, Provider name in blank)Special Education/ Early Intervention (if yes, Provider name in blank)

OtherOther

Does the family have a SAFETY PLAN?

Yes (attach copy below or specify its terms here)Yes (attach copy below or specify its terms here)

No

Safety Plan Upload

Maximum file size: 516MB

Court Involvement (attach court order below if available)

None

Supervision

Supervision & Protection

Protection order in place

Pending Court Hearing: (include date & time)Pending Court Hearing: (include date & time)

Court Order Upload

Maximum file size: 516MB

Synopsis of Relevant History

Primary problematic behaviors of the child

Specific skills and parenting strategies to address

Briefly state the PRIMARY GOAL(S)

At least 1 goal is required. List up to 3.

Priority Area(s) of Support Focus

Family’s Presenting Strengths

Specific Safety Concerns: Please check any that apply to the youth/family/home location where services will be provided (within the last year)

Suicide or self-harm behaviors (if a safety plan is in place, please send a copy)

Ongoing domestic violence

Inappropriate use of weapons

Sexual abuse

Sexual offender living in the home

Gang involvement

Ongoing lice or bed bug infestation

Unsafe pets

Active substance use

Additional Comments

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Kinship Support Referral Form