Heart Gallery of Lane County

A Family For Every Child
Heart Gallery
541-343-2856
877-343-2856 christy@afamilyforeverychild.org

Tax I.D. 20-4151057
Christy Obie~Barrett
Executive Director
880 Beltline Road
Springfield, OR 97477
fax 541-343-2866

OUR MISSION:
To find loving, permanent families for every waiting foster child.

Heart Gallery Mentor Program Youth Referral Form

Date:
Date caseworker reviewed:
Would you like to be at the match with the mentor and the youth? Yes No
Caseworker Name:
Phone:
Email:

Foster Parent Name(s):

Phone:
Address:
Email:
Other Contact Info:

Foster Youth Name:
Phone:
Address:
Other Contact Info:
Age and Birthday:
Gender:	F M
Ethnicity:
Language:
Ethnicity preferred for Mentor:
Required:	Yes No
Has this youth been adjudicated:	Yes No
If yes, please describe:
Youth legally free:	Yes No
In OCP Program?	Yes No (required)
If yes, (optional) OCP Case Manager Name: Phone:
Can youth have photo taken:	Yes No
Can youth have video taken:	Yes No
Will the youth remain in DHS care/custody at least one year after match?	Yes No
Is this child on the adoption track?	Yes No
Are the parent(s) of this child incarcerated?	Yes No
If so, which parent?

Please check below up to 5 of the child's known interests or activities:

Arts & Crafts

Cooking

Sewing

Movies / TV

Reading

Computers / Electronics

Sports

Dolls

Dress-Up

Biking

Swimming

Hiking

Bowling

Fishing

Camping

Animals

Golfing

Music

Dancing

Video Games

Other interests and hobbies: