Power of Story Young People

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
Your Name *

First Name Last Name
Your Email *
example@example.com
County or organization you are employed through

Anoka Carver Dakota Hennepin Ramsey Scott Washington Other
Is this referral for an...? *
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. *

Clear
Young Person's Name *

First Name Middle Name Last Name
Young Person's Date of Birth *

Month Day Year
Date
Young Person's Race (check all that apply) *

African American/Black American Indian/Native Alaskan Asian/Pacific Islander White
Hispanic Heritage? *

Yes No
Will you refer siblings for this youth today? *

No 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 Diabetes Cystic Fibrosis Huntington's Disease Depression Stroke High Blood Pressure Sickle Cell Anemia Neurofibromatosis Cancer High Cholesterol Alzheimer's Disease Thyroid conditions Suicide (attempted or achieved) Bipolar Disorder Anxiety Disorder Schizophrenia Alcohol/Drug abuse or dependency Borderline Personality Disorder Learning disabilities or disorders ADHD or ADD Autism Spectrum Disorder Auto Immune Disorder Other genetic disorders Other
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

First Name Last Name
Email of Program Manager
example@example.com
Share photos, artwork or documents here.

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.
Cancel of
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.
Phone Number *
Please enter a valid phone number.
Should be Empty:

Power of Story Young People

Not Currently Accepting Referrals