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About
Board of Directors
Annual Report/Financials
How We Help
Leadership
Client Stories
Youth Shelters
Youth Shelter Referral Form
Bed Availability
Brittany's Place
>
Transitional Living Program(TLP)
>
TLP Application
Community-Based Services
>
Parent Support Program - Application
Hope House
St. Cloud Youth Shelter
Von Wald Youth Shelter
Foster Care
Community Re-Entry
Safe Harbor & Supportive Services
Outreach Services
Safe Harbor Navigator: East Metro
Engage
Employment
Events
Speaking Engagments
Volunteer
News
CrossCurrents 180 Degrees Blog
The Turnaround Newsletter
Donate
In-Kind Donations
Contact Us
Parent support program application
*
Indicates required field
How did you find out about the parent support program?
*
180 Degrees staff
180 Degrees website
Word of Mouth
Youth or family at 180 Degrees
Other
If Other please specify:
*
Who is making the referral?
Name
*
First
Last
[object Object]
Title
*
Relationship (to youth or guardian)
*
Self
Social Services
Court Services
Probation
Law Enforcement
Other
If Other please specify:
*
Agency
*
Contact Information
Phone Number
*
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Guardian/Family Information
Guardian Name
*
First
Last
Relationship to youth
*
Parent
Non-parent guardian/caregiver
Family member
Phone Number
*
Email
*
County
*
Anoka
Chisago
Dakota
Isanti
Ramsey
Washington
Hennepin
Other
If Other please specify:
*
Was permission given by the guardian/family to be contacted by a parent liaison?
*
Yes
No
Unknown
Youth Information
Name
*
First
Last
Preferred Name
*
First
Last
Age
*
Where is the youth residing?
*
Brittany's Place
Other
If other, please specify
*
Background
What brings the family/guardian to need support services?
*
Known presenting concerns: Family or youth? Check all that apply
*
Housing
Substance Use
Mental Health
Self-Harm
Trauma, Abuse (physical, emotional, sexual), Neglect, Physical abuse
Trafficking/Exploitation (human, sex, labor)
Gender/Sexual Orientation
Safety Needs
Medical Needs
Other high risk behaviors
Behavioral concerns
School concerns
Employment concerns
Financial concerns
Cognitive vulnerability
Criminal history or legal concerns
Gang affiliation
Trouble navigating the "system"
Transportation
Cultural needs
Other, please specify
Please explain concerns below
*
Services Needed/Desired (check all that apply)
*
Resources
Emotional support
Referrals
Education on exploitation/trafficking
Other
If other, please specify
*
Submit
