Agency Referral Form

This referral form is intended for use by community providers, agencies, therapists, and other professionals who wish to refer an individual to Women & Family Life Center (W&FLC). Please complete the form with as much relevant information as possible to help our team best support the referred participant.

W&FLC provides programming for individuals residing within our 15-town service area: Branford, Chester, Clinton, Deep River, Durham, East Haven, Essex, Guilford, Killingworth, Madison, Middlefield, North Branford, North Haven, Old Saybrook, and Westbrook. While referrals submitted by professionals should be for individuals living within this service area, our team will make every effort to ensure that anyone seeking support is guided toward appropriate resources whenever possible.

Agency Referral Form

The referral form must be completed in full and accompanied by a signed Release of Information (ROI) for the referring party and any other relevant parties.

Completed documents may be faxed to (203) 458-0616 or emailed to programs@womenandfamilylife.org.

Please allow up to two business days for follow-up. Referred participants will also be required to complete an intake with W&FLC staff.

If you have any questions, please call (203) 458-6699 and ask to speak with a Referral Navigator or the Director of Programs..

WFLC Agency Referral Form 2025 (Rev.2026) (pdf)

Download

Agency Referral Form

Agency Referral Form

Cookie Policy