PSOP Referral - St. Louis County MN

Date:

Location of family being referred:

South (Duluth, Floodwood, Brookston, Meadowlands)

North (Hibbing, Virginia, Ely)

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/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 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

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?

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)

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):

Parent Support Outreach Referral

Parent Support Outreach Referral Form

Family Information

Parents/Caregivers Information

Parent 1

Parent 2

Other Adult

Children's Information

Eligibility Information

Referring source information: