Advocacy Referral

Submitter Information

Date*

Submitter Name*

First Last

Submitter Email*

Relation to the Youth*

Youth Information

FSFN ID

Youth Name*

First Last

Youth Phone Number*

Youth Email

Date of Birth*

Gender*

Female
Male

Ethnicity*

Parental Rights Terminated?*

Yes
No
Pending
Unknown

Address where youth resides:*

Street Address Address Line 2 City State ZIP Code

County of Residence*

Orange
Osceola
Seminole
Other

Advocacy services are limited to youth living in Orange, Osceola and Seminole county, at this time.

Placement Type*

Housing Type*

Transitional Housing Name

Number of placement changes in the last year*

Group Home Name*

Has anyone in the most recent placement tested positive for COVID-19?*

Does the youth have a diagnosis: mental, physical, behavioral, educational, etc?*

Please attach CBHA

Is the youth currently enrolled in one of the following programs?*

EFC
PESS
Opted out of care
N/A

In FFC Tutoring or FFC funded classes/lessons?*

Is the youth a parent?*

Is the youth pregnant?*

Is the youth incarcerated?*

Is the youth actively participating in school?*

Educational History

School Currently Attending*

School Type*

Grade*

Number of schools changes in the last year*

Number of retentions throughout school history:*

Has the youth taken the GED or any portion of it?*

Is this student in Exceptional Student Education (ESE)?*

Is this student in English Speakers of Other Languages (ESOL)?*

Does this student have an IEP?*

Please attach IEP

Please attach most recent grades

Primary Support - Caregiver Information

Primary Support Name*

First Last

Primary Support Number*

Primary Support Email*

Is this your Primary Support contact OR your Caregiver contact?*

Primary Support
Caregiver

Child Welfare Team Information

This is your child welfare team information such as your Case Manager, IL Specialist/TSS or GAL

Who will be the primary contact for Advocacy services*

If other, please indicate role*

Is the case likely to close in the next two months?*

Child Welfare Team: Primary Contact Name*

First Last

Child Welfare Team: Primary Contact Phone Number*

Child Welfare Team: Primary Contact Email*

Case Management Agency*

CHS
GCJFS
OHU

County Case Managed Out of:*

Orange
Seminole
Osceola

Youth Services Manager Name

First Last

Youth Services Manager Phone Number

Youth Services Manager Email

Please include the name, phone number and email of any other child welfare team members to be included in collaboration & communication.

Date of the next scheduled youth transition meeting

Release of Information

By signing below, I approve the release of the confidential information provided in this referral to FFC, its contracted tutoring agencies and its funding agencies, including but not limited to, Orange County Commission for Children and Embrace Families.

Electronic Signature: Release of Information*

Please type first and last name

Electronic Signature: Release of Information

By checking this box you accept this electronic signature.

Consent to Services

Advocacy services include: supportive services, life skills development and training, and financial support through Empower Success Funding. Advocates work with youth to strengthen independence and support their goals. This includes identifying individual needs and linking youth to internal programs and community resources. The Advocate provides advocacy, planning and coaching to ensure each youth receives personalized support to achieve success. Youth 18 and older must provide direct consent before services will be initiated. Consent must be provided by the caregiver, caregiver support, IL specialist, TSS, GAL or their respective supervisors before services will be initiated for youth 14-17.

I agree to meet with Advocate weekly, prepared to participate in meetings and coordinated activities. In addition, I agree to attend workshops & actively participate in all aspects of program delivery.*

Due to Covid-19, a number of FFC activities and events have been moved to virtual platforms. The youth's Advocate will assist with coordinating access.

I agree the youth will meet with Advocate weekly, prepared to participate in meetings and coordinated activities. In addition, the youth will attend workshops & participate in all aspects of program delivery.*

Due to Covid-19, a number of FFC activities and events have been moved to virtual platforms. The youth's Advocate will assist with coordinating access.

Consent to Services Statement*

By signing below, I hereby give the Foundation for Foster Children (FFC) consent to provide Advocacy services to the youth named herein. I understand this includes Advocate meetings with youth and professionals such as caregivers, school personnel and employers. I agree to share notes and records, in addition to provide consent to Advocate to share information, as necessary, to maximize collaboration and communication; and will inform the Advocate of any upcoming meetings regarding the youth’s needs, including Youth Transition meetings, IEP meetings; parent-teacher conferences, etc.

Consent to Services Statement*

By signing below, I hereby give the Foundation for Foster Children (FFC) consent to provide me (youth named herein) with Advocacy services. I understand this includes Advocate meetings with myself and my support team including professional such as child welfare team and school personnel. I agree share records and that the Advocate may share information, as necessary, to maximize service delivery; and I will inform my Advocate of any upcoming meetings regarding my needs, including Youth Transition meetings, IEP meetings, etc.

Electronic Signature: Consent to Services*

Please type first and last name

Electronic Signature Consent to Services

By checking this box you accept this electronic signature.

Photo/Testimony Release

Foundation for Foster Children Photo/Testimony Release: provides the Foundation for Foster Children (FFC) with permission to use photographs or testimonies provided in internal and external communications such as program newsletters and FFC marketing materials including, but not limited to, the website and print materials of FFC. Youth 18 and older must provide direct consent before services will be initiated. Consent must be provided by the caregiver, caregiver support, IL specialist, TSS, GAL or their respective supervisors before services will be initiated for youth 14-17.

Photo/Testimony Release: Consent*

I do give consent
I do not give consent
I do not have permission to provide consent

Photo/Testimony Release Statement*

By signing below, I hereby give the Foundation for Foster Children (FFC) permission to use photographs or testimonies of the youth named herein. I understand that FFC may use photographs and testimonies in internal and external communications including program newsletters and FFC marketing materials including, but not limited to, the website and print materials. I understand that compensation in any form for the use of this likeness is prohibited.

Photo/Testimony Release Statement*

By signing below, I hereby do not give the Foundation for Foster Children (FFC) permission to use photographs or testimonies of the youth named herein.

Photo/Testimony Release Statement*

By signing below, I hereby am unable to give/deny the Foundation for Foster Children (FFC) permission to use photographs or testimonies of the youth named herein.

Please provide the name, phone and email address of the individual with permission to provide/deny photo consent.

Electronic Signature: Photo/Testimony Release*

Electronic Signature: Photo/Testimony Release

By checking this box you accept this electronic signature.

Submitter Information

Youth Information

Educational History

Primary Support - Caregiver Information

Child Welfare Team Information

Release of Information

Consent to Services

Photo/Testimony Release

Section Break