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.
Today's Date
*
Caregiver 1
Parent 1 Last Name
*
Parent 1 Legal First Name
*
Parent 1 Preferred First Name
*
Parent 1 Preferred Phone Number
*
Enter International
Parent 1 Cell Phone
Enter International
Parent 1 Email
Parent 1 Race
Arab, Iranian or Middle Eastern
Asian
Black/African American
Hispanic or Latino
Multi-Racial
Native American or Alaska Native
Other
Pacific Islander or Native Hawaiian
Unknown
White
Cultural/Racial/Ethnic Heritage Details
If applicable, please note Native American heritage & tribe*
Which of the following best describes your gender identity?
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Parent 1 Pronouns
How would you describe your sexual orientation?
Asexual
Asexual, Queer
Bi / queer
Bisexual
Gay/lesbian
Heterosexual
Other
Pansexual
Queer
Queer/Questioning
Unknown
Parent 1 Preferred Language
*
Home Address
Street Address
*
Street Address Line 2
State
*
Select US-State
AK - Alaska
AL - Alabama
AR - Arkansas
AS - American Samoa
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
FM - Federated States of Micronesia
GA - Georgia
GU - Guam
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MH - Marshall Islands
MI - Michigan
MN - Minnesota
MO - Missouri
MP - Northern Mariana Islands
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
PW - Palau
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VI - Virgin Islands
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Enter Region
City
*
Zip Code
*
County
Family Preferred Contact Method
Home Phone
Parent 1 Email
Parent 2 Email
Parent 1 Cell Phone
Parent 1 Work Email
Parent 2 Work Email
Parent 2 Cell Phone
Parent 1 Work Phone
Parent 2 Work Phone
Caregiver 2
If applicable
Parent 2 Last Name
Parent 2 Legal First Name
Parent 2 Preferred First Name
Parent 2 Cell Phone
Enter International
Parent 2 Email
Parent 2 Race
Arab, Iranian or Middle Eastern
Asian
Black/African American
Hispanic or Latino
Multi-Racial
Native American or Alaska Native
Other
Pacific Islander or Native Hawaiian
Unknown
White
Cultural/Racial/Ethnic Heritage Details
If applicable, please note Native American heritage & tribe*
Parent 2 Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Parent 2 Pronouns
Parent 2 Sexual Orientation
Gay/lesbian
Other
Asexual
Asexual, Queer
Bisexual
Bisexual / Pansexual
Heterosexual
Pansexual
Queer
Queer/Bisexual
Queer/Questioning
Unknown
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
Select US-State
AK - Alaska
AL - Alabama
AR - Arkansas
AS - American Samoa
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
FM - Federated States of Micronesia
GA - Georgia
GU - Guam
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MH - Marshall Islands
MI - Michigan
MN - Minnesota
MO - Missouri
MP - Northern Mariana Islands
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
PW - Palau
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VI - Virgin Islands
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Enter Region
Mailing Zip Code
Referrer Information (If self-referral by family please leave blank)
Your name
Organization/Title
Phone #
Enter International
Email
Does the family know they are being referred to this program?
Yes
No
What Services and Resources Are You Seeking for the Family (Check all that apply)?
Accessing Medical Care
Becoming licensed as a foster parent
Financial Supports (TANF, etc.)
Housing
Items for the youth like clothing, school supplies, etc.
Legal Supports
Mental health Supports
Nutrition and Food (WIC, etc.)
Support Groups/Self-Care
Other Services/Resources Sought
Children in Home
People in Home
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
First Name
*
Last Name
*
Birth Date
*
Relationship to Caregivers
Child
Cousin
Friend
Grandchild
Great Grandchild
Nephew/Niece
Other
Sibling
Step-Child
Step-Sibling
Is child birth, foster, adoptive, or guardianship?
Adopted
Birth
Foster
Guardianship
Gender
Female
Male
Genderfluid
Transgender Female
Agender
Child Gender
Gender non-conforming
Non-Binary
Non-Binary (legally female)
Other
Transgender Male
Transmasculine
Two-spirit
Pronouns
She/Her
He/Him
They/Them
Other (list below)
DCYF Social Worker (if foster child)
Submit
