RPACS Referral Form: Post-Adoption and Kinship Permanency Support

These services require that the family resides in Virginia. For adoptive families, families must have a legal, finalized adoption of any type. Kinship families must have legal guardianship and be enrolled in KinGAP or receive state funded subsidy. The youngest adopted or kinship youth must be under 18 years of age. In special circumstances, families can continue to receive services until their adopted or kinship youth is 21 years of age.

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

RPACS Referral Form: Post-Adoption and Kinship Permanency Support

Family Information

Reason for Referral

Person Completing Referral Form