Minor Parent Referral
Form
February 25, 2026
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
