Help Them Take the Next Step — Refer Today!

Are you connected to a youth in foster care, ages 16 to 21, who’s ready to grow, thrive, and plan for a strong future? The Family Connection in Lafayette, LA is here to walk alongside them with support, resources, and real-world guidance. Whether it’s life skills, education, housing support, or simply a safe space to be heard — we’re ready. Make a referral today and help bridge the gap between foster care and adulthood!

Referral Form

Date of Referral*

Month

Day

Year

Time

:HoursMinutes

Is the client aware that a referral has been made on their behalf? Please provide any information that is pertinent to the client that is being referred. *

Yes

No

Is this referral urgent? Please provide additional information below.*

Yes

No

Referring Agency*

Contact Person*

Contact number*

Position Held*

Participant's Information

Participant's First name*

Participant's Last name*

Medicaid Number (If none, type N/A)*

Participant's Contact number*

Birthdate (Must be between 16 and 21 years of age)*

Month

Day

Year

Email*

Phone*

Multi-line address

Country/Region

Address

City

Zip / Postal code

Immediate Needs: (check all that apply)*

Emergency Shelter

Clothing

School Supplies

School Uniforms

Employment Assistance

None

113 Jared Drive

Broussard, LA 70518

337-393-0747 (Phone)

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