Post-Adoption Services (RPACS)

Today's Date*
Month
Day
Year
Name of family referred for services*
First Last
Parent/Legal Guardian 1*
First Last
Parent/Legal Guardian 1 Date of Birth
MM slash DD slash YYYY
Parent/Legal Guardian 1 Ethnicity
Parent/Legal Guardian 1 Race
Parent/Legal Guardian 2
First Last
Parent/Legal Guardian 2 Date of Birth
MM slash DD slash YYYY
Parent/Legal Guardian 2 Ethnicity
Parent/Legal Guardian 2 Race
Primary phone number*
Secondary Phone Number
Primary email*
Secondary email
Physical Address*
Street Address Address Line 2 City State ZIP Code
Mailing address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
County*
Family Information
Marital status
Parent(s) race(s)
Child information
Child's name* DOB* Gender Relationship (i.e. Adopted child, kinship, biological, foster child, other)* Race/Ethnicity

You have the ability to add up to 5 rows in this chart. Click the "+" sign on the right to add a new information row. Please contact us if you will need any additions. Please note that columns with * are required.
Does the family referred have a legal, finalized adoption?*
- Yes
- No
Type of adoption (check all that apply)*
- Foster Care
- Private/Domestic
- International
Does the family have legal guardianship of a relative/fictive kin?*
- Yes
- No
Does the family receive KinGap?*
- Yes
- No
Does the family receive Kinship State Subsidy?*
- Yes
- No
Reason for Referral
Please provide a brief description of why you are referring the family to post-adoption or kinship support services and list any current family needs:*
(i.e.: training/education, peer support, family events, behavioral challenges, birth family connections)
Please list any current services accessed by family
Person Completing Referral Form
First Name*
Last Name*
Providing your first and last name above represents your digital signature for this form.
Phone number*
Email address*
Organization (if applicable)
CAPTCHA
Date
MM slash DD slash YYYY
Date
MM slash DD slash YYYY

Child's name*	DOB*	Gender	Relationship (i.e. Adopted child, kinship, biological, foster child, other)*	Race/Ethnicity

Post-Adoption Services (RPACS)

Family Information

Reason for Referral

Person Completing Referral Form