Agency Referral Form

This referral form should be used by any community provider, agency, therapist, or any other professional who is interested in referring a person to W&FLC. This form should be completed with as much relevant information as possible. W&FLC can only offer programming to people located in the 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.

 The form should be completed in its entirety, along with ROI for referring party and any relevant parties. 

Documents may be faxed to (203) 458-0616 or emailed to: info@womenandfamilylife.org. Please allow 2 business days for follow up. Participants will need to complete an intake with W&FLC staff.  Any questions please call (203) 458-6699 and ask to speak to a Referral Navigator or Program Manager.