• TLC: The Love Continues — Professional & Agency Referral Form

    Refer a child, young adult, or family to TLC with the key contact and needs information—only share confidential details with appropriate permission.

  • Referring Professional

  • Format: (000) 000-0000.
  • Preferred Contact Method*

  • Family Information

  • Format: (000) 000-0000.
  • Has the family agreed to be contacted by Love & Protect Wisdom?*

  • Child / Young Adult

  • Are there additional children or young adults impacted?*
  • Additional Children / Young Adults
  • If yes, provide each additional child's or young adult's first name, age, and relationship to the deceased parent/caregiver.

  • Referral Information

  • Has the child or young adult lost a parent or primary caregiver due to domestic violence homicide?*
  • Approximate date of loss
     - -
    2 digit month, 2 digit day, 4 digit year

  • Identified Needs

  • Identified needs*
  • Is there an urgent need TLC should be aware of?*
  • Is the family currently connected to other services?*

  • Additional Information

  • May Love & Protect Wisdom contact you regarding this referral?*

  • Certification

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: