A Family For Every Child
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A Family For Every Child
Phone: 541-343-2856
Toll-Free: 877-343-2856
info@afamilyforeverychild.org
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A Family For Every Child
1675 West 11th Avenue
Eugene, OR 97402

Fax: 541-343-2866

Tax I.D. 20-4151057

Christy Obie-Barrett,
Executive Director

A Family For Every Child is a non-profit organization that serves families, children, and agencies nationwide. Thank you for all your support.

Heart Gallery Mentor Program
Youth Referral Form

Red fields are required

Date:

Date caseworker reviewed:

Would you like to be at the match with the mentor and the youth?
Caseworker Name:
Phone:
Email:
 
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:
Birth Month & Year (MM/YYYY):
Gender:    
Ethnicity:
Language:
Ethnicity preferred for Mentor:
Required:   
Do you want the child to receive educational assistance from the mentor?       Allows mentors to connect with the child's school in order to help them academically.
Do you want the child to participate in life skills training?       Mentors and children attend regular classes and are given a curriculum covering basic life skills.
Has this youth been adjudicated:   
If yes, please describe:
 
In OCP Program?      
If yes, (optional) OCP Case Manager Name:
Phone:
 
Can youth have photo taken:   
Can youth have video taken:   
 
Will the youth remain in DHS care/custody at least one year after match?   
 
Is this child on the adoption track?   
Youth legally free:   
 
What is the case plan for the child? Where do you see it heading?
 
Are the parent(s) of this child incarcerated?   
If so, which parent?
 
 
Please check below up to 5 of the child's known interests or activities:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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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