Power of Story Young People
When you have added as much information as you can, hit SUBMIT at the bottom of the form to securely send this information to us (256 Bit SSL Encryption).
Today I would like to
Make a referral for a Social Medical History or Lifebook
Add to a young person's story (answer questions + share photos/documents)
ONLY share documents/photos for a young person
County or organization you are employed through
Is this referral for an...?
Initial Social Medical History + Lifebook Combo
Initial Social Medical History
Updated Social Medical History + Lifebook Combo
Updated Social Medical History
I have discussed this referral with my supervisor and have gotten the go ahead to refer this young person to Power of Story for this service.
Young Person's Name
Young Person's Date of Birth
Young Person's Race (check all that apply)
American Indian/Native Alaskan
Will you refer siblings for this youth today?
Yes, and I have not yet submitted their information (each sibling is referred separately - after you hit submit, you can resubmit for additional siblings)
Yes, and I already submitted their information.
Give us an overview of their story so far.
Describe them to us.
Personality, interests, favorites, behaviors, strengths, weaknesses, relationships with others, positive and negative behaviors
Tell us about their entrance into foster care.
Who lived with them before they came into care, date and why they entered foster care.
Tell us about their educational history.
Schools and preschools attended, assessments/IEP/504, subjects excelled at or struggled in, relationships with peers.
Tell us about their birth.
Pregnancy, prenatal care, complications during pregnancy or birth, full term, C-section/assisted/normal, Apgar scores.
Tell us about their personal medical and mental health situation.
Past and current illnesses, hospitalizations, surgery's, medications, allergies, immunizations, evaluations, mental health, medical and dental providers.
Tell us about their family medical history
Heart Disease/heart attack
High Blood Pressure
Sickle Cell Anemia
Suicide (attempted or achieved)
Alcohol/Drug abuse or dependency
Borderline Personality Disorder
Learning disabilities or disorders
ADHD or ADD
Autism Spectrum Disorder
Auto Immune Disorder
Other genetic disorders
Tell us more about the items you checked above. Who in the family had what?
How did it effect them?
Tell us about their birth/first/natural Mom.
Past information about her childhood and growing up years, as well as a current physical description and personality, interests, favorites, behaviors, strengths, weaknesses, relationships with others, positive and negative behaviors.
Tell us about their birth/first/natural Dad.
Past information about his childhood and growing up years, as well as a current physical description and personality, interests, favorites, behaviors, strengths, weaknesses, relationships with others, positive and negative behaviors.
Tell us what you know about their siblings.
Names, ages, are they living together or separate, how well do they get along, and often to do they visit, etc.
What else would like them to know about their story?
You can write a note directly to them, share about other important people, other important facts, stories or information.
Not Currently Accepting Referrals
We are not currently accepting new referrals but would be happy to connect with your program manager, provide more information about our services, and a rate sheet to see if we might work together. Provide their information below and we will reach out right away.
Name of Program Manager
Email of Program Manager
Share photos, artwork or documents here.
Drag and drop files here
Choose a file
We securely accept the following file types: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif, with no maximum file size.
Who else should we talk do about this? How can we get in touch with them?
Would you like a follow up call to share more?
Yes, and my schedule is wide open, have a staff call me.
Yes, I will schedule a time that works for my schedule online after I hit submit.
No, I shared everything I know already.
Please enter a valid phone number.
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