Young People

Lifebook or Social Medical History Referral Form

MN Workers Complete Refer Below
Note: We offer a limited number of Lifebook scholarships to fosters and adoptees, ages 18-28, who are not working with a social worker. Interested young people can apply for scholarship using this link.
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*
Young Person's Contact Information*
Race (check all that apply)*

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

YesNo
Gender*

MaleFemaleOther
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
Birth mom's name and contact info.*
Enter all that is known, email and phone preferred. In case of adoption disruption, please list the former adoptive parent AND birth parent's information.
Birth dad's name and contact info.*
Enter all that is known, email and phone preferred. In case of adoption disruption, please list the former adoptive parent AND birth parent's information.
Current Caregivers Are?*

Not In Foster CareShelter/Residential/Group HomeExtended Foster CareKinship FosterKinship Transfer of Permanent Legal and Physical Custody (TPLPC)Kinship Adoption FinalizedNon-relative FosterNon-relative Pre-AdoptiveNon-relative Adoption Finalized
Current Caregiver Name*

First NameLast Name
Current Caregiver Email*
Please provide if you have - example@example.com
Current Caregiver Phone*
Please enter a valid phone number.
Will translation be needed to speak with birth parents or caregivers?*

Yes, share primary language(s) belowNo, English is primary language
Other people to contact for this young person and contact Info
Enter all that is known, email and phone preferred.
Your Name*

FirstLast
Your Email*
example@example.com
Your Phone*
Other workers involved in this life history and their contact info.
CP Worker/Ongoing Worker/ GAL etc.
County or organization you represent*

Ain Dah YungAnokaConnections to IndependenceDakotaScottStearnsWashingtonOther
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 and agree to be billed upon it's completion.*

Clear
Use finger or computer mouse to sign.

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.
- Birth Certificate
- Immunization Record
- Most recent GAL and SW Report to Court
- CHIPS Court Record
- Out of Home Placement Plan (OHPP)
- Medical records - both birth and ongoing
- TPR Petition (if applicable)
- TPR Filing (if applicable)
- Contact information for family (birth, foster and adoptive)
- Educational Record (Schools attended, IEP/504/Assessments)
- Developmental Screenings/ASQ Questionnaires
- Previous Lifebooks or SMH’s
- Dental records
- Psychological evaluations
- Psychiatric evaluations
- Diagnostic assessments
- Therapeutic progress reports
- Photos, artwork, letters, etc.
Upload 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.
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What records have not yet received and when were they requested?*
If all records you have requested are already in and shared, please note that above.
Should be Empty:

Lifebook or Social Medical History Referral Form