At Mara’s Lighthouse, we’re honored to partner with the Early Childhood Court program to support young children and families navigating the child welfare system. Our ECC team provides trauma-informed, relationship-based therapy and care coordination that promotes healing, stability, and family reunification.

Please use this form to refer a child or family for ECC services. Once submitted, our clinical team will review the referral and contact the appropriate parties to begin the intake and coordination process.

Referral Source:

Name and Title

Office Phone:

(###)

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Cell Phone:

(###)

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Agency:

FSC Supervisor Name:

Phone

(###)

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Client and Family Information

First Name

Last Name

Reason for Referral:

Phone

(###)

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Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent's Name:

First Name

Last Name

Parent's Phone Number:

(###)

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Parental Rights Status

Case Plan Goal

Current Caregiver's Name

First Name

Last Name

Phone

(###)

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Name of School:

Are other services being provided?

If so, please provide the name of the service and provider:

Are other members of the family in services at DCF?

If so, provide the name(s) of the family member(s) and providers if known:

Insurance Information

Insurance Carrier

Subscriber ID Number:

FOLLOW US: