Power180 Online Youth Shelter Referral Form

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?:

Yes

Unknown

*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)

Other Youth Information

*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: