Cinderella Project School Social Worker and Counselor Referral Form

Your Information

Name of Individual Submitting this referral

Relationship to Student

Student Information

Student's First Name

Student's Last Name

Student's Gender Identity

Other Gender Identity (please specify)

Student's Racial Identity

Other Race Identity (please specify)

Is the student in foster care or was in foster care and is now adopted/legal guardianship?

Student's Legal Status

Student's Cell Phone

Email Address Student Checks Regularly

Name of High School

Grade

Date of Prom

Adult Contact Information

Social Worker/Counselor Name

Social Worker/Counselor Phone

Social Worker/Counselor Email

Caregiver Name

Caregiver Phone

Caregiver Email

Appointment Information

Who will bring the student to the appointment?

What is the best email or phone for the person bringing the student?

Estimated Dress Size

Shopping days will be from Wednesday March 1st to Wednesday March 8th. Please choose 3 preferred appointment times. Our Family Enrichment Manager will contact you with an assigned appointment.

Preferred Appointment Times (Hold down CTRL and Choose 3 please)

The Cinderella Boutique is located at ReFresh 1710 S. Brentwood Blvd., St. Louis MO 63144

Visit our website at http://www.foster-adopt.org/cinderallaproject for more information.

For more information, contact Madison Brown, Family Enrichment and Volunteer Manager at 314.806.2556 or madisonbrown@foster-adopt.org