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
4211 W. 11th Ave
Eugene OR 97402
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 legal free:	Yes No
Can youth have photo 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 list other programs and activities that the youth is currently involved in:

Youth's interests and hobbies: