Kinship Referral Form

This form is to be completed by the REFERRAL AGENCY. Information on this form will be kept confidential and will be used to assist Kinship in matching the child with an appropriate adult volunteer.

Referring Agency:

Address:

Street Address City State ZIP Code

Contact Person:

First Last

Title:

Phone Number:

Ext.:

Email Address

Child’s Data

Name:

First Last

Home Phone:

Child Living With:

First Last

Relationship to Child:

Address

Street Address Mailing Address City State ZIP Code

Date of Birth:

Ethnic Origin:

Gender:

Legal Guardian:

First Last

Language Spoken in Home:

Mobility of Child and Family

Does the child/family move often?

Comments:

Family Child History

Is there any history of any of the following?

Physical Abuse
Sexual Abuse/Incest
Neglect
Chemical Dependency/Alcoholism
Suicidal Tendencies
Disability, Handicap, Illness
Rape/Teen Pregnancy
Mental Health Issues
None of the above

Please Explain:

Child’s Self-Esteem

What is the child’s attitude toward self?

Very Good
Good
Fair
Poor

Please Explain:

School/Education Information

School child is currently attending:

Grade Level:

Teacher:

First Last

Phone Number:

School Counselor/Social Worker:

First Last

Person with Whom Child Relates Best:

Child’s Attitude Towards School:

Child’s Behavior in School:

Subjects Child Most Enjoys:

Participation in School Activities:

Legal Data

Do you know of any other agencies working with this child?

Please list any of which you know:

Recommendations for Matching

How do you think an adult volunteer would help this child?

What type of person would you suggest we match with this child?

Other Comments:

Date

Type name

Signature

Kinship Referral Form