Community Referral Form

Miami, FL

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 Child Welfare Involvement? (Please check all that apply)
Client has an assigned Case Manager and is working on a reunification plan with Child Welfare Authorities. (Only check if client has a current court order)
Children are living out of the home placement (relative, non-relative)
Open Investigation - children are at-risk of being removed from the client
Domestic Violence
Mental Health
Substance Abuse
No Support in Place

Someone from the ĒMA team will follow up to schedule an intake and assessment. How would this client like to complete our intake and assessment process? Select their preference:

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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