SPEAKOUT WORKER FORM

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(THIS FORM IS FOR STAFF USE ONLY: For youth who are still in care and/or receiving services from DSS.)

If the youth is still in care and/or receiving services from DSS, the youth's DSS worker must also fill out the worker form.
The Virginia Department of Social Services recognizes that we do better work with the input of those impacted by our policies. We need the voice of youth to make a difference in the way youth are served in the foster care system.

SPEAKOUT is for youth in foster care and alumni who are willing to provide input on foster care regulations, policy, guidance, and practice concerns, while also building advocacy and leadership skills.

The group will ideally consist of 15-20 foster youth from across the state. It is expected that the group will meet several times a year to discuss issues and share ideas with VDSS. During the first two meetings, participants will be making decisions about the structure and format of the group moving forward.

If you have any questions, please email Speakout@dss.virginia.gov or contact Chauncey Strong or Em Parente:

Chauncey Strong, MSW
Youth Development Specialist
Chauncey.strong@dss.virginia.gov
(804) 229-2211

Em Parente
Foster Care & Family Engagement Program Manager
Em.Parente@dss.virginia.gov
(804) 726-7538

Youth Information

Youth First Name *

Youth Last Name *

Select Region that Holds Custody of Youth *

Youth's Gender *

Youth's Race *

Youth's Phone Number *

Youth's Age *

Type of Placement *

If other, please specify:

Placement Contact Person's First and Last Name *

Placement Contact Person's Phone *

Name of Youth's Custodial Agency *

Family Services Specialist/Social Worker's First and Last Name *

Family Services Specialist/Social Worker's Phone *

Family Services Specialist/Social Worker's Email *

Public Relations Consent

SPEAKOUT may use audio or visual recordings for a variety of publicity purposes. I realize that the use of such is strictly voluntary and at my discretion. My decision whether to grant consent or not will not affect services. I have been informed and understand the confidentiality policy and the confidential nature of information and will not hold SPEAKOUT liable for voluntarily or inadvertently disclosing information. *

Yes, I consent to SPEAKOUT using this youth's photo and/or first name for publicity purposes. This may include using quotes or posting group or individual pictures on our website or social media pages.

No, I do not consent to SPEAKOUT using this youth's photo or first name for publicity purposes.

This youth is 18 or older and will provide his/her own consent.

Transportation and Permission to Contact Youth

For youth under the age of 18: By typing my name below, I am granting permission for staff to transport (if necessary) this registered youth to and from activities for SPEAKOUT events. I also grant permission for the staff to contact this registered youth after this event through email, phone and/or Facebook. *

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