Mothers Advocacy Project Referral to MAP Program

Thank you for referring a mom to MAP.

Due to privacy concerns, we will not follow-up with you, but you will receive confirmation of submission via e-mail. If you are a DFCS Case Manager or Attorney, you will be contacted once the client has given the proper permissions. Please be sure to put YOUR name in the Referrer's First and Last Name field, NOT the person that you are referring. You will enter their name further down on the form.
Today's Date*

MonthDayYear
Date
Referrer's First and Last Name*
Referrer's Email*
example@example.com
How did you hear about MAP?
What is your relationship to the person you're referring?*

DFCS Case ManagerService ProviderFriendRelativeOther
Does this person know that you are referring them to MAP?*

YesNo
Potential Client Information
Potential Client's Name*

First NameLast Name
Potential Client's Email*
example@example.com
Potential Client's Phone Number*
Please enter a valid phone number.
Their preferred method of communication, if known:

CallTextEmail
What County is the Potential Client in?*
If the potential client's County of Residence was not listed above, what county does she live in?
Is the Potential Client a Single Mother with custody of at least one child under 18?*

YesNo
Number of Children:
Does the potential client have an open DFCS case?*

YesNo
If there is an open case, what it the projected closure date?
Is there anything else you'd like our staff to know - please be brief in your response.
Has the person you're referring ever been involved with Mothers Advocacy Project before (that you know of)?
Once again, thank you for referring a potential client to MAP. Due to privacy concerns, we will not follow-up with you, but you will receive a confirmation message upon submission. Please do not submit this form twice for the same client. If you are a DFCS Case Manager or Attorney, you will be contacted once the client has given the proper permissions. If you need to change or add to what you've submitted, please contact: Call / Text to 470.280.6655 or Email clientservices@mapfamily.org.
Should be Empty:

Thank you for referring a mom to MAP.

Potential Client Information