Agency & Attorney Referral Form
Use this form to refer families to The Toby Center for Family Transitions. For attorneys, judges, Guardian ad Litems, and agency partners in Florida.
Your Information
Your Full Name
*
First Name
Last Name
Your Professional Title
*
Please Select
Attorney
Guardian ad Litem
DCF Case Manager
Judge / Judge's Office
School Counselor
Agency Case Manager
Other
Organization or Firm Name
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Florida Bar Number (for attorneys)
Client Information
Client First Name
*
Client Last Name
*
Client Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client Email
example@example.com
County where case is filed
*
Case / Court Order Number
Service being requested
*
Please Select
Supervised Visitation
Monitored Child Exchange
Both Supervised Visitation + Child Exchange
Reunification Therapy
Therapeutic Supervised Visitation
Family Court Mediation
Family Therapy / Counseling
Case Information
Is there a current court order?
*
Yes
No
In Progress
Court Order Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are there any safety concerns or restrictions we should be aware of?
Preferred service start date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional notes for our intake team
Upload Court Order (PDF)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Referral
Should be Empty: