Online Direct Representation Attorney Referral Form

Referral for Children Who Need Direct Representation Attorney

Referrals are for children who want an attorney to represent them in their CHINS/TPR case. To make a referral, either fill out this form or call or text Rachel Vilensky at 317-721-6711.

Name

Name of person completing this form.

First Last

Email address of person completing this form.

Phone

Phone number of person completing this form.

Relationship to Child

Client Information

Please fill out all information known

Child's Legal Name

Child's Preferred / Chosen Name

Child's Pronouns

Date of Birth

Child's Native Language

Child's Phone Number

Child's Email

Guardian ad litem / CASA Name

Provide name if known.

Cause Number

If known

Next Court Date

Current Placement of Child

Placement Location

Please select from one of the following options and additional field(s) will display to complete for your selection.

Emergency Shelter/Placement

Residential Placement

Foster / Kinship / Relative / In-Home Care

Placement Name

Foster / Kinship / Relative / In-Home Caregiver's Name

Caregiver's Relationship to Child

Caregiver's Phone Number

Caregiver's Email Address

Direct Representation Referral Categories

(Check All That Apply)

Child is 12+

Child's Wishes Different Than GAL Recommendation

Residential Placement

Detective Request Child Interview

Sex Offense Allegations Against Child

Additional Reasons for Referral

Name

This field is for validation purposes and should be left unchanged.

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