Young People

Power of Story Young People

Refer
What should this young person receive?*
*UPDATE only when initial SMH and Lifebooks also completed WITH Power of Story.
Young Person's Name*

FirstMiddle (if known)Last
Date of Birth*

MonthDayYear
Current Age*
Race (check all that apply)*

African American/BlackAmerican Indian/Native AlaskanAsian/Pacific IslanderWhiteOther
Hispanic Heritage?*

YesNo
Gender*

MaleFemaleOther
Describe them to us.*
Personality, interests, favorites, strengths, weaknesses, relationships, nicknames, highs and lows.
What do you want to make sure they know?*
Lessons they have taught you, dreams for their future, important people, other important facts, stories or information.
Will sibling(s) also be referred today?*

NoYes, and I have not submitted their information yetYes, and I already submitted their information
Sibling(s) Names
Which best describes their current caregivers?*

Not In Foster CareExtended Foster CareKinship FosterKinship Transfer of Permanent Legal and Physical Custody (TPLPC)Kinship Adoption FinalizedNon-relative FosterNon-relative Pre-AdoptiveNon-relative Adoption Finalized
Your Name*

FirstLast
Email*
example@example.com
Phone*
County or organization you represent

AnokaDakotaScottSouthwest Health and Human ServicesWashingtonWinonaOther
Sign if you have discussed this referral with your supervisor and have the go ahead to refer this young person to Power of Story for this service.*

Use finger or mouse to sign. Clear

Upload Documents, Photos or Artwork
The more information we have at the time of referral, the quicker the process will proceed. Please upload all of the following that you have quick, easy access to.
- Placement List
- Contact information for family (birth, foster and adoptive)
- Out of Home Placement Plan (OHPP)
- Birth Certificate
- Immunization Record
- Educational Record (Schools attended, IEP/504/Assessments)
- Previous Lifebooks or SMH’s
- Court Record (CHIPS and TPR)
- Reports to Court
- Medical records
- Dental records
- Psychological evaluations
- Psychiatric evaluations
- Diagnostic assessments
- Therapeutic progress reports
- Photos, artwork, letters, etc.
Upload Here

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More About Them
Their Birth and Early Years
First memories, visits in the hospital, or as a newborn, pregnancy, prenatal care, complications during pregnancy or birth.
Their Medical and Mental Health Information
Illnesses, hospitalizations, surgery's, medications, allergies, immunizations, evaluations, mental health, medical and dental providers.
Their Education
Schools and preschools attended, assessments/IEP/504, subjects excelled at or struggled in, relationships with peers.

Out-of-Home Experiences
When They Moved Into Out-of-Home Care.
What life was like BEFORE moving into care, and why they entered out of home care.
Their Experiences In Out-of-Home Care.
Relationships made, traditions, memories from caregivers, highs and lows.

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Power of Story Young People