Online Youth Shelter Referral Form


Thank you for referring a youth to a 180 Degrees shelter. After completing this form, you'll hear back within 24 hours. For urgent needs or questions, please contact the shelter directly after submission. Our contact information is below.

Acknowledgements:
  • Stay Duration: Up to 90 days; longer stays require approval.
  • Safety: Our shelters are open 24/7/365. We are not a locked facility; youth may leave anytime, but are encouraged to stay until a safe, stable exit is possible.

House Expectations:
  • Our shelters are a safe space. We provide a safe environment where all identities are respected and hate has no place.
  • We do allow phones, but with limited hours, guardian approval required.
  • We do not allow smoking or vaping onsite.
  • We ask everyone to participate in programming based on need and ability.
  • Alternate Placement: If we are not able to meet a youth's needs, we may ask for your help to find a more suitable place.
  • Confidentiality: Your privacy is essential. We will not share private information, however we are mandated reporters that are required to report child or vulnerable adult abuse, if we believe a person’s life is in danger, or if we think a person may be a danger to others.

For Youth/Parents/Guardians:
  • Parental consent needed within 72 hours for those under 18.
  • Certain services, like medication, require signed intake forms.

For Professionals/County Workers:
  • Complete intake forms within 24 hours for full services.
  • Send authorization documentation/court order/voluntary placement agreement within 24 hours.



Referral/Screen Date:


  *Shelter Preference(s) (check all that apply)

Hope House
  • Located in Chanhassen, MN
  • All genders, ages 14-19
  • Phone: 612-900-2077
  • Text: 612-916-3977
     Vonwald Youth Shelter
  • Located in Rochester, MN
  • All genders, ages 12-19
  • Phone: 507-280-0110
  • Text: 507-202-5873
Brittany's Place
  • Located in east St. Paul, MN
  • Female, female-identifying
    (no male-identifying), ages 10-19
  • Phone: 651-287-4801
  • Text: 612-295-2913
     St. Cloud Youth Shelter
  • Located in St. Cloud, MN
  • All genders, ages 12-19
  • Phone: 320-259-6764
  • Text: 320-434-3600


  Information about the person making the referral

*Name of person
making the referral:
Title:
**Phone: **Email:
*Relationship to youth: *How did you find out about 180 Degrees?:
Same as youth
needing shelter?:


  Information about youth needing shelter

*First Name: *Last Name:
Preferred Name
if different:
Pronouns:
Address Line: City:
State: Zip:
Phone: Email:
*Date of Birth:
(MM/DD/YYYY)
Age:
(Auto-populated from Date of Birth)
*Gender: *Expected Placement Date:
(MM/DD/YYYY)


Check if immediate need/ crisis/needs bed now:   
*Is this for a
county-ordered placement?:
*If yes, county:

*What brings youth to need shelter services?:

  Please check all that apply either currently or within the past 12 months with details if applicable
  (at least one is required)

Housing (e.g. homelessness, runaway) or household concerns
Household Dynamics
Failed Placement
Trauma, abuse or neglect
Mental health needs
Medical/physical health needs
Chemical dependency/substance abuse
High risk behaviors
Behavioral concerns
School concerns
Employment/income concerns
Cognitive vulnerability
Sexual orientation/gender identity concerns
Sex exploitation/trafficking concerns
Labor exploitation/trafficking concerns
Criminal history or legal charges
Gang affiliation
Other, please specify


  Other Youth Information

*Currently employed?:   
Notes/Explain:
*Currently attending/enrolled in school?:   
Notes/Explain:
*Is the family involved? Describe family situation/dynamics:   
Notes/Explain:
*Ability to have a roommate:   
Notes/Explain:
*Specialized programming needed?:   
Notes/Explain:

*Last two places youth has resided:
(e.g. residential treatment, group home, shelter, family home)


Enter any other important information below:


  Information about the legal guardian

Name of legal guardian: Phone:
Email:    




    











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