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.

Please note: MAP serves single moms (or women with custody of minor children). We provide free mental health services and assist women with becoming stable, as we are able, upon entry to our program.

We do not provide housing.

We do not provide direct services for children.

We do not have a Spanish-speaking representative on staff at this time.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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?

Other
Does this person know that you are referring them to MAP?
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.Format: (000) 000-0000.
Their preferred method of communication, if known:
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?
Number of Children:
Does the potential client have an open DFCS case?
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