Name(Required) First Last Pronouns(Required) He/Him/His She/Her/Hers They/Them/Theirs Other Phone(Required)Email(Required) County of Residence(Required)AitkinAnokaBeckerBeltramiBentonBig StoneBlue EarthBrownCarltonCarverCassChippewaChisagoClayClearwaterCookCottonwoodCrow WingDakotaDodgeDouglasFaribaultFillmoreFreebornGoodhueGrantHennepinHoustonHubbardIsantiItascaJacksonKanabecKandiyohiKittsonKoochichingLac qui ParleLakeLake of the WoodsLe SueurLincolnLyonMahnomenMarshallMartinMcLeodMeekerMille LacsMorrisonMowerMurrayNicolletNoblesNormanOlmstedOtter TailPenningtonPinePipestonePolkPopeRamseyRed LakeRedwoodRenvilleRiceRockRoseauSaint LouisScottSherburneSibleyStearnsSteeleStevensSwiftToddTraverseWabashaWadenaWasecaWashingtonWatonwanWilkinWinonaWrightYellow MedicineI am interested in learning more about (select all that apply) Foster care Kinship care (pre-finalization) Kinship adoption (post-adoption resources) Kinship guardianship (post-guardianship resources) Adoption (pre-finalization) Adoption (post-adoption resources) Therapeutic services Peer support Parents and caregivers Children and/or teens Training opportunities I am a professional in need of resources for a youth or family. Yes MessagePlease let us know what's on your mind. Have a question for us? Ask away.Overview & Confidentiality Statement(Required) By checking this box and including your signature below, you are acknowledging that you have read and agreed to this Confidentiality Statement.Overview of Permanency Services Resource Hub and Confidentiality Statement Overview of Services The Permanency Services Resource Hub provides referrals to the PSS and PPAI services and resources available to you. Within 2-3 business days of receiving your submission of the Permanency Services Resource Hub Contact Form, Foster Adopt MN staff will respond directly to your request. This may include connecting you directly to the Permanency Services contact at the appropriate PSS or PPAI agency, as applicable. Confidentiality Parameters and Consent to Permanency Services Resource Hub Sharing Information By signing this form, you understand and consent that only your contact information and the basic information regarding your resource and support request(s) (as indicated on your Contact Form in Sections 1 and 2) will be shared with the appropriate contact at a participating PSS or PPAI agency that best matches your request(s). All other information you choose to share on the contact form remains confidential with the Permanency Services Resource Hub. Exceptions to the above confidentiality parameters are: If you provide expressed written consent to share your information with another entity/service provider outside of the participating PSS or PPAI agencies. If you disclose information that is required by statute or court order to be reported to the appropriate state or county agency (e.g. reporting threat of harm to self or others; known or suspected abuse or neglect of a vulnerable adult or child within the last 3 years). If disclosure is required by the Permanency Support Services contract between Foster Adopt Minnesota and the Minnesota Department of Human Services. By signing below you agree that: You understand the information included above; You consent to participating in communication with the Permanency Services Resource Hub for the purposes of information and/or referral regarding PPAI or PSS agencies and their services; You are at least 18 years old and have the capacity to consent and sign this form.Name(Required) Electronic Signature (Type in First and Last Name) Foster Adopt MN staff will respond to your message within 2-3 business days. For questions, please contact us at info@permanencyhubmn.orgPhoneThis field is for validation purposes and should be left unchanged. Δ
