Heart Gallery Mentor Program Youth Referral Form

Date:
    

Date caseworker reviewed:
 




Caseworker Name:
  
Phone:
 
Email:
 
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Foster Parent Name(s):
  
  
Is This a Relative Placement?
Foster Parent Phone:
  
Foster Parent Address:
  
Foster Parent Email:
  
Other Contact Info:
  
 
Does this Child Have a CASA?
CASA Name
CASA Email
CASA Phone
 
Does the youth see a therapist regularly? (yes/no)
 
Foster Youth Name:
  
Phone:
  
Address:
  
Other Contact Info:
 
Age and Birthday:
 
Gender:
 F   M      
Ethnicity:
  
Language:
  
Ethnicity preferred for Mentor:
  
Required:
 Yes   No  
Has this youth been adjudicated:
 Yes   No  
If yes, please describe:
 
In OCP Program?
Yes   No  (required)
If yes, (optional) OCP Case Manager Name:
Phone:
Can youth have photo taken:
 Yes   No  
Can youth have video taken:
 Yes   No  
Will the youth remain in
DHS care/custody at least
one year after match?
Yes   No

Is this child on the adoption track? 		Yes   No  
Youth legally free:
Yes   No  
What is the case plan for the child? Where do you see it heading?  

Are the parent(s) of this child incarcerated? 		Yes   No  

If so, which parent? 		 
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Please check below up to 5 of the child's known interests or activities:
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Other interests and hobbies:
Additional Notes: Are there any behaviors or safety concerns that a mentor should be aware of? Please provide as much as you would like the mentor to know that would be helpful in relating to this child.
Please enter any additional information that would be helpful to the mentor:
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