Minor Parent Referral
Form
January 14, 2025
Minor Parent Referral Form
Date:
Location of family being referred:
South (Duluth, Floodwood, Brookston, Meadowlands)
North (Hibbing, Virginia, Ely)
Minor Parent's Name:
Address:
City:
State:
Zip Code:
Phone:
Date of Birth:
Social Security Number:
Is the minor parent aware of this referral being made?
Yes
No
Estimated Due Date:
Prenatal Care?
Yes
No
Presumed Father's Name:
Address:
City:
State:
Zip Code:
Doctor/Clinic:
Address:
City:
State:
Zip Code:
Identified Stress Factors:
Domestic Violence
Mental Health Concerns
Homelessness/Housing Concerns
School/Educational Concerns
Trauma Exposure
Limited Support System
Grief/Loss
Chemical Use Concerns
Disability
Medical Concerns
Low Income/Poverty
Human/Sex Trafficking Concerns
Other (Please Explain)
Identified Needs:
Public Health Nurse
Chemical Dependency Services
Childcare Assistance (Application and Resources)
Application For Assistance (Food/Cash/Medical)
Support Groups
WIC
Therapy Referrals
Housing Services
Assistance With Items For Baby
Education/Work Planning
Transportation Assistance
Parent Education Resources
Other (Please Explain)
Are there immediate safety concerns? If yes, please explain:
What are the strengths and known supports:
Share any additional information necessary for this referral:
Referring source information:
Name:
Role:
Contact Phone Number:
Email Address:
Submit
