Program 1 Date of Referral Referring Staff Name Phone Referring CITC Department and Program or Other Agency Name ID: 854218
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1 CITC’s Child & Family Services Luqu Ke
CITC’s Child & Family Services Luqu Kenu Program 1 Date of Referral :_____________ Referring Staff Name: ______________________ ________ Phone: _______________ Referring CITC Department and Program or Other Agency Name: _________________________ Participant’s N ame : ______________ _________________________________________ _ Date of Birth: ___________ __ Participant’s Phone: _____ _________________ Participant’s Mailing Address: _______________________________ __ C hildren’s names :__________________________________________________________________________________ _________________________________________________________________________________________________ _______ ____ Describe any current needs this parent has expressed: _______ _______________________________ _______________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ ______________ ___________________________________________________________________________________ Luqu Kenu Screening G uidelines : Luqu Kenu is a program designed to provide support for Alaska Native and/or American Indian who have physical and legal custody of their children and reside in the Anchorage area . Does this family reside in the Municipality of Anchorage? Yes No Does this family identify as Alaska Native and/or American Indian? Yes No ( Please n ote that this does include non - Native parents or caregivers of AN/AI children. ) Physical Custody: Does this parent have physical custody? Yes No ( Please note that physical custody generally means the biological parent(s) live with their children , or if a caregiver, they have a court order . If you have questions about physical custody, please feel free to call us at 907 - 793 - 3177. ) Legal Custody: Does this parent have legal custody? Yes No ( Generally speaking, if parents or caregivers have the authority to enroll their children in school or take them to the doctor, that means that they have legal custody of their children. If you have questions about legal custody, please feel free to call us at 907 - 793 - 3177. ) Ha s the family granted permission for us to contact them by phone? Yes No current Release of Information (ROI) from this participant with this referral? Yes No We appreciate receiving a copy of the current ROI with the referral when ever possible. Thank you for this referral. We look forward to connecting with this participant! ~ Your Luqu Kenu team LUQU KENU PROGRAM REFERRAL FORM Referrals can be emailed to: luqukenu@citci.org . For program related questions please call: (907)793 - 3177. To send in the referral by fax, please fax to: (908) 793 - 3173.