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Get in touch

555-555-5555

mymail@mailservice.com

What We Do
How We Do It
Who We Serve
Resources for Youth
Support FHL
- Donate Now

referral form

Referral Form

Name of Child (required)

First Name:

Last Name

Date of Birth

Age

Ethnicity

Gender Expression

Child's Parish of Residence

Child's Region of Residence

DCFS Case Manager (required)

DCFS First Name

DCFS Last Name

DCFS Case Manager Phone

DCFS Case Manager Email

DCFS Case Manager's Parish

DCFS Case Manager's Supervisor (required)

DCFS Case Manager's Supervisor First Name

DCFS Case Manager's Supervisor Last Name

Name and Address of Residential Facility (if applicable)

Foster Parent's First Name

Foster Parent's Last Name

Foster Parent's Address

Address 1

Address 2

City

State

Zip Code

Country

Foster Parent's Phone

Foster Parent's Email

Does child have a CASA?

CASA Volunteer Name (if applicable)

CASA First Name

CASA Last Name

CASA Volunteer Phone Number

CASA Volunteer Email Address

Name of Child's Current Dentist (required)

Dentist First Name

Dentist's Last Name

Dentist's Phone Number

Dentist Address 1

Dentist Address 2

Dentist City

Dentist State

Dentist Zip Code

Date of Last Dental Appointment (required)

Date of Next Dental Appointment (required)

Check all that apply:

Ten years of age or older

Currently in foster care

Free of delinquent behavior or delinquency matter resolved

Free of runaway behavior

Free of ungovernable behavior

Able to maintain consistency in placement

Able to maintain consistent school attendance

New Option

Able to maintain a C average or better in school

New Option

Enrolled in or near appropriate grade level

Reliable transportation child to and from orthodontist appointments

Verbal commitment from caregiver to transport child to and from orthodontist appointments

If no to any of the above, explain why child should be considered for braces

Name of judge presiding over child's case (required)

Judge First Name

Judge Last Name

Thank you for your submission. A referral has been received indicating that you would like a foster child to be considered for free braces.

To continue the selection process, please email several dates and times of your availability to discuss the child's eligibility.

We look forward to hearing from you.

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P.O. Box 2126
Prairieville, LA 70769

admin@fhlouisiana.org

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