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Online Direct Representation Referral Form

*Referrals are for children who are in agreement with attorney representation in their CHINS/TPR case*

Referrals submitted through this form are sent to Rachel Roman-Lagunas with Child Advocates.

Referrals are reviewed on a rolling basis. You will receive an email regarding your referral in 7-10 days.

Referral Date
Name

Child's Information

Please fill out all information known
Child's Name
Date of Birth
DCS Case Manager Name
Guardian Ad Litem Name
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.
Caregiver's Home Address
Direct Representation Referral Categories
(Check All That Apply)
This field is for validation purposes and should be left unchanged.