Parent Support Outreach Referral
Form
May 09, 2024
Parent Support Outreach Referral Form
Date:
Location of family being referred:
South (Duluth, Floodwood, Brookston, Meadowlands)
North (Hibbing, Virginia, Ely)
Family Information
Parents/Caregivers Information
Parent 1
Parent/Caregiver Name:
Date of Birth:
Gender:
Male
Female
Non-binary/third gender
Prefer to self-describe
Prefer not to respond
Race:
Caucasian
Black or African American
American Indian/Alaskan Native
Pacific Islander
Other
Declined
Unknown
Hispanic Heritage:
Yes
No
Unknown
Any Known Disabilities:
Yes
No
Unknown
Parent 2
Parent/Caregiver Name:
Date of Birth:
Gender:
Male
Female
Non-binary/third gender
Prefer to self-describe
Prefer not to respond
Race:
Caucasian
Black or African American
American Indian/Alaskan Native
Pacific Islander
Other
Declined
Unknown
Hispanic Heritage:
Yes
No
Unknown
Any Known Disabilities:
Yes
No
Unknown
Other Adult
Other Adult Name:
Date of Birth:
Gender:
Male
Female
Non-binary/third gender
Prefer to self-describe
Prefer not to respond
Race:
Caucasian
Black or African American
American Indian/Alaskan Native
Pacific Islander
Other
Declined
Unknown
Hispanic Heritage:
Yes
No
Unknown
Any Known Disabilities:
Yes
No
Unknown
Children's Information
Child Name:
Date of Birth:
Gender:
Male
Female
Non-binary/third gender
Prefer to self-describe
Prefer not to respond
Race:
Caucasian
Black or African American
American Indian/Alaskan Native
Pacific Islander
Other
Declined
Unknown
Hispanic Heritage:
Yes
No
Unknown
Any Known Disabilities:
Yes
No
Unknown
If child is age 5 or under: Has referral been made for a developmental screening thorugh Help Me Grow or the local school district?
Yes
No
Unknown
+ Add Child
Family Street Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email Address (if known):
Are any family members enrolled or eligible for enrollment with any federally recognized American Indian tribe?
Yes
No
If yes, which household member?
If yes, which tribe?
Does the family speak english?
Yes
No
If no, what is the preferred language of the family?
If no, is an interpretor needed?
Eligibility Information
Does the family have a child age 10 or under or is the parent caregiver pregnant?(if no ineligible)
Yes
No
Does the family have current involvement with child protection?(if yes ineligible)
Yes
No
What are the family's identified stress factors? (at least 2 to be eligible)
Domestic Violence
Mental Health Concerns (parent or child)
Chemical Use Concerns (parent or child)
Low Income/Poverty
Homelessness/Housing Concerns
Parent/Caregiver Separation
Prior Child Protection History
Parenting Challenges
Child Behavior Concerns
Limited Support System
Disability (parent or child)
Human/Sex Trafficking Concerns
School/Education Concerns
Legal Issues
Medical Concerns (parent or child)
Trauma Exposure
Grief/Loss
Other (Please Explain)
What is/are the reason(s) for the referral?
Are there immediate safety concerns for the family? If yes,describe:
What are the family's strengths and known supports?
Share any additional information necessary for this referral:
Is the minor parent aware of this referral being made?
Yes
No
Referring source information:
Name:
Role:
Street Address:
City:
State:
Zip Code:
Phone Number:
Email Address (if known):
Submit
