Home | Contact Us

A-OK REFERRAL FORM

Thank you for referring this child to the A-OK Program. We work very hard to identify prospective adoptive parents for all children referred to us. There is no fee to refer a child. If you have the time, it would be helpful if you could complete as much of the intake below as possible. If you prefer to discuss the intake with one of our staff, we would be happy to get back to you and we can complete the intake information by telephone (so we can save you time inputting the information.) In the meantime, if you could please upload background information so we can get to know the child you are referring, we would appreciate it. Please scroll to the bottom of the intake and upload the information. A summary, social history, and photo are very important for us to get started. No identifying information will be shared with prospective adoptive parents.

Do you work with a foster child in need of a forever adoptive home?
Appropriate referrals to the A-OK program are children legally freed for adoption in the United States foster care system. Children must be referred by a social worker who is authorized to recruit adoptive families for that child. Children can be age 0-21 with varying levels of special needs. They can be single or part of a sibling group. Upon referral, STAR will seek to match the child with one of our waiting families that have been specially trained and have a current home study to adopt a child from the foster care system. Social workers can also select additional recruitment tools to feature the child in the STAR newsletter and/or our website to increase their chance of finding an adoptive home.

Child Information
Child First Name*
Child Nick Name
Child Last Name
Child Birth Date* Calendar
Personality Narrative
This is the child’s profile or write up that is usually used in photo listings. You may also provide a link to the child’s photo listing here
Personality Narrative*
Referral
(name of agency, organization, county or person making referral)
Referral Source*
Additional referral information
Child Case Manager
Child’s Case Manager*
Child’s Adoption Recruiter
Name of Agency
Telephone number*
()-ext
Enter Int'l Number
Case Manager E-Mail*
Case Manager County
Mailing address
Other important contact information
CONTACT INFORMATION
When did the child enter care?
Where/with whom they lived prior to coming into care?
Reasons for entering care
How many placements has the child had since entering care?
Please describe placements has the child had since entering care
Where is the child residing?  
Please describe where is the child residing
Please describe length of current placement and assess stability
Has the child experienced a disrupted adoption?
If yes, explain disrupted adoption
Is the child freed for adoption?
Is the child apart of a sibling group?
If yes, how many siblings  
If yes, list names and ages of siblings
Are all of the above children freed for adoption?
Please describe siblings
Are the children currently placed together?
If not, how long have they been separated?
Are the children recommended to be placed together?
Child Race  
Gender  
Does the child identify as LGBTQIA+?
Additional Contact Information
MEDICAL
Does the child have any medical issues?
If yes, please describe medical issues
Does the child have any known drug or alcohol abuse?
If yes, please describe drug/alcohol abuse
Additional medical information
EDUCATIONAL
Is the child currently enrolled in a school setting?
How has the child adjusted to this setting?
Does the child have an IEP?
Additional educational information
COGNITIVE
Does the child display any signs of cognitive developmental delays?
If yes, describe cognitive developmental delays
Additional cognitive information
SPEECH/LANGUAGE
Does the child display any signs of speech or language delays?
If yes, describe speech or language delays
Does the child have a hearing impairment?
If yes, describe hearing impairment
What is the child’s vocabulary like?
Is English the child’s first language?
If no, what is the child’s first language?
Does the child speak other languages?
If yes, what languages?
Does the child receive Speech Therapy?
If yes, how often does the child receive Speech Therapy?
Additional speech/language information
PHYSICAL- GROSS AND FINE MOTOR
Does the child walk independently?
If yes, at what age did the child begin walking?
Does the child display any gross motor delays or challenges?
If yes, please describe any gross motor delays or challenges
Does the child display any fine motor delays or challenges?
If yes, please describe any fine motor delays or challenges
If age appropriate, can the child write?
If yes, describe writing ability
Does the child receive occupational therapy?
If yes, how often does the child receive occupational therapy?
Does the child receive physical therapy?
If yes, how often does the child receive physical therapy?
SOCIAL/EMOTIONAL
How does the child deal with separation?
How does the child deal with anger or frustration?
What are the child’s fears?
What are the child’s favorite toys, games and activities?
What are the child’s favorite foods?
Does the child sleep through the night?
Does the child take naps during the day?
If yes, describe nap schedule
Does the child display any sleep problems?
If yes, describe any sleep problems
Does the child display any problems with transitions from one activity to another?
If yes, describe problems with transitions from one activity to another
Any known past physical, sexual or emotional abuse?
If yes, describe past physical, sexual or emotional abuse
Does the child know or understand that adoption is being considered?
Is the child attending counseling?
If yes, explain counseling?
Does the child have behavioral issues/psychological diagnosis?
Please describe behavioral issues/psychological diagnosis
Does the child display signs of an attachment disorder?
 
Please describe signs of an attachment disorder
Who diagnosed the child with behavioral or attachment disorder? (example: physician, foster family, caseworker, therapist)
Is the child on any psychotropic medications?
Has the child received emergency services for mental health evaluation?
Has the child ever been arrested?
If yes, describe arrest
Has the child every run away?
If yes, describe the run away
Is the child sexually active?
Is child religious?
If yes, what religion does child identify with?
Additional social/emotional information
SIGNIFICANT RELATIONSHIPS
Please give a brief description of individuals the child relates to in their daily life? (such as foster parents, birth family members, siblings, close family friends, educators, counselors, etc.)
Additional information regarding significant relationships
OTHER
What type of adoptive family is being recommended for this child?
Are there any geographic limitations on a prospective adoptive family?
Describe geographic limitations
What is the child looking for in an adoptive family?
Does the child have experience living with younger children?
Please explain experience living with younger children
Does the child have experience living with older children?
Please explain experience living with older children
Is the child on a Safety Plan?
Please explain Safety Plan
Does the child have experience living with pets?
Please explain experience living with pets
Other Additional information
UPLOADS
MEDICAL
EDUCATIONAL
PSYCHOLOGICAL
OTHER DOCUMENT
UPLOAD PHOTO
SUMMARY
OTHER UPLOAD
I give permission for this child’s photo and personality narrative to be used for a one time feature in the STAR newsletter.
I give permission for this child’s photo and personality narrative to be featured on the STAR website for up to 3 months. I will notify Adoption STAR if the child is no longer available before the 3 month feature is over
By clicking the Save/Submit button below you agree to InReach Solutions' Terms of Service and Privacy Policy
 
Submitting...