Amara

Referral - Amara Kin Connections Program

Eligibility
We welcome your referral to the Kin Connections program at Amara. Before completing this referral please confirm:
The caregiver is caring for youth who are in foster care (i.e., they are a “formal” kinship family)
The kinship family lives in Pierce or King County
*For ICPC cases, there is an active ICPC case where the youth are placed and/or the family has begun the ICPC licensing process.
*leave blank if n/a **We are unable to work with families who are interested in pursuing ICPC but there is no active case open yet**
Today's Date* Calendar
Caregiver 1
  
Parent 1 Last Name*
Parent 1 Legal First Name*
Parent 1 Preferred First Name*
Parent 1 Preferred Phone Number*
()-ext
Enter Int'l Number
Parent 1 Cell Phone
()-ext
Enter Int'l Number
Parent 1 Email
Parent 1 Race
 
Cultural/Racial/Ethnic Heritage Details
If applicable, please note Native American heritage & tribe*
Which of the following best describes your gender identity?  
Parent 1 Pronouns
How would you describe your sexual orientation?  
Parent 1 Preferred Language*
Home Address
Street Address*
Street Address Line 2
State/Region*
Enter Region
City*
Zip Code*
County
Family Preferred Contact Method
 
Caregiver 2
If applicable
Parent 2 Last Name
Parent 2 Legal First Name
Parent 2 Preferred First Name
Parent 2 Cell Phone
()-ext
Enter Int'l Number
Parent 2 Email
Parent 2 Race
 
Cultural/Racial/Ethnic Heritage Details
If applicable, please note Native American heritage & tribe*
Parent 2 Gender  
Parent 2 Pronouns
Parent 2 Sexual Orientation  
Parent 2 Preferred Language
Mailing Address
if different from home address; leave blank if n/a
Mailing Street Address
Mailing Street Address Line 2
Mailing City
Mailing State/Region
Enter Region
Mailing Zip Code
Referrer Information (If self-referral by family please leave blank)
Your name
Organization/Title
Phone #
()-ext
Enter Int'l Number
Email
Does the family know they are being referred to this program?
What Services and Resources Are You Seeking for the Family (Check all that apply)?
 
Other Services/Resources Sought
Children in Home
  People in Home
 

 		  
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