The Homecoming Project - Referral

All youth referred to The Homecoming Project must be registered on the State Adoption Exchange (SAE). If this youth is not registered, please do so prior to referral.

Any questions - contact us at 612-861-7115 or email homecominginfo@mnadopt.org

Youth Information
Youth Name	First		Middle
	Last		Suffix		(jr., II)
Date of Birth	mm/dd/yyyy
DHS#		Census#
Race 1		Race 2
Number of Siblings		Siblings to be Placed Together?		Yes No
Does ICWA Apply?	Yes No
Comments
Referring Social Worker	First Last
Agency
Address 1
Address 2
City, State, Zip	,
Phone
Fax
E-mail
Other Worker 1 (select one)	Guardian Ad Litem Mental Health Worker Child Service Worker Probation Officer Other
Name of Worker	First Last
Agency
Address 1
Address 2
City, State, Zip	,
Phone
Fax
E-mail
Other Worker 2 (select one)	Guardian Ad Litem Mental Health Worker Child Service Worker Probation Officer Other
Name of Worker	First Last
Agency
Address 1
Address 2
City, State, Zip	,
Phone
Fax
E-mail
Other Worker 3 (select one)	Guardian Ad Litem Mental Health Worker Child Service Worker Probation Officer Other
Name of Worker	First Last
Agency
Address 1
Address 2
City, State, Zip	,
Phone
Fax
E-mail
Current Living Situation (select one)	Foster Care, relative/kinship	Shelter		Group Home
	Foster Care, non-relative	Hospital		Residential Treatment
	Other
Name of Foster Parent(s)	First Last First Last
Address 1
City, State, Zip	,
Phone
E-mail
Name of Supervising Worker of Foster Parent(s)	First Last
County Agency
Address 1
Address 2
City, State, Zip	,
Phone
Fax
E-mail
Name of Facility (RTC, correctional placement, shelter)
Name of Primary Worker	First Last
Address 1
Address 2
City, State, Zip	,
Phone
Fax
E-mail
Placement History
Date of first out-of-home placement	mm/dd/yyyy
Reason for initial placement
Number of times returned home
TPR Date	mm/dd/yyyy
Beginning date of current continuous out-of-home placement	mm/dd/yyyy
Length of time at current placement	months days years
Number of adoption disruptions (prior to finalization)
Number of adoption dissolutions (after finalization)
Assessment and Diagnoses Information
Difficulty of care points (from most recent assessment)
Is there a CAFAS Assessment completed within the past 6 months?	Yes No If yes, please attach
Mental Health Diagnosis (if any)
Physical Disabilities (if any)
Corrections History (if any)	Number of times arrested Charges
School Information
What grade is the youth in?
Name of School
Contact Person	First Last
Address 1
Address 2
City, State, Zip	,
Phone
Is there an IEP?	Yes No Unknown
Type of services receiving:
Birth Family Information
Is Birth Mother living?	Yes No Unknown
Is Birth Father living?	Yes No Unknown
Briefly describe type, quality, and frequency of contact between youth, siblings and/or birth parents and/or other member of birth family.
Program Participation
List the top three reasons it has been challenging to find a family for this youth.	Reason 1
	Reason 2
	Reason 3
Youth's reaction to participating in The Homecoming Project
Foster parent/care provider reaction to youth's involvement in The Homecoming Project
Previous recruitment efforts made on behalf of this youth (check all that apply)	Registered on SAE	Thursday's Child		Presented at Task Force
	Adoption List-Serv	Newspaper		Child Specific Recruitment
	Adoption Video Show/Special Event	Other
Is there a travel file available on this youth?	Yes No

Completion Instructions:

Print Form for Your Records: Use button below to access print screen. This form cannot be saved.

Print and complete this Release of Information form and mail to MARN or fax to 612-861-7112.

Submit Referral: Use button below to submit your referral after completing the above 2 steps.

It is important that youth and foster parent(s)/care providers initially hear about The Homecoming Project from you, the youth's social worker. Please talk with them and give them an overview of the project before making this referral. In addition to this form, you must complete a Release of Information with an original signature.