Heart Gallery Mentor Program Youth Referral Form

Date:
    

Date caseworker reviewed:
 




Caseworker Name:
  
Phone:
 
Email:
 
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Foster Parent Name(s):
  
  
Phone:
  
Address:
  
Email:
  
Other Contact Info:
  
 
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:
 
Youth legally free:
Yes   No  
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  

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: