Community Referral Form

938 Mezzanine Dr Ste. B Lafayette, IN, 33026

If you are a community agency with a client in need of our services – please fill out our referral form and our team will be in touch with you shortly.

Agency Information
Agency Details
Your Info
Client Information
Known DCF Involvement? (Please check all that apply)
DCF Court Orders
Children in licensed foster care
Children in out of home placement (relative, non-relative)
Open Investigation - My children are at-risk of being removed from my care
Conflicts with Father of Children
No Social Support in Place
Criminal History
Substance Abuse History
Mental Health Disorders
Financial Crisis

By checking this box, I agree that I received written or verbal consent from my client to disclose the information provided in this referral for the purpose of Every Mother’s Advocate (ĒMA) services to be considered. My client further consents to be contacted via phone by the ĒMA Case Management team upon referral approval.

Signature Disclaimer: By signing your name electronically on the Every Mother’s Advocate, Inc. Community Referral, you are agreeing that your electronic signature is the legal equivalent of your manual signature on this submission form. You further agree by signing your name electronically that the information provided within this document is fully transparent, accurate, and the signature is made with intent. Upon signing this document electronically, a copy will be sent directly to the e-mail provided once processed by the Every Mother’s Advocate, Inc. Case Management team. By signing your name electronically, you acknowledge that you have the option to opt-out of digital signing in favor or a paper referral form that would be provided to you upon request.

To complete your electronic signature, please type your FULL LEGAL NAME in the box below:

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