Get Help Name* First Last Email* Phone*County of Residence*(Please Select)BrevardCharlotteClayCollierCitrusDeSotoDuvalGladesHendryHernandoHillsboroughIndian RiverLakeLeeManateeMarionMartinNassauOkechobeePalm BeachPascoPinellasSarasotaSeminoleSt. LucieSt. JohnsSumterOtherHiddenState HiddenCounty of Residence How many children?*Primary Reason for Referral*(Please select one)Childcare while giving birthDomestic ViolenceHomelessnessIncarcerationMedical EmergencyMental HealthMentoringParent UnavailableSubstance AbuseUnemployedWeekend RespiteOther (Explain)Additional Reasons for Referral: Childcare while giving birth Domestic Violence Homelessness Incarceration Medical Emergency Mental Health Mentoring Parent Unavailable Substance Abuse Unemployed Weekend Respite Other (Explain) Other (Explain) Do you have an open case with the Department of Children and Families?*YesNoChild Protective Investigator Name First Last Child Protective Investigator PhoneHow did you hear about us?*(Please select one)OnlineFacebookCommunity ResourceDepartment of Children and FamiliesPregnancy Resource CenterHospital/Doctor’s OfficeSheriff's DepartmentSchool DistrictShelterFriendChurchSelf ReferralOtherOther (Explain)*EmailThis field is for validation purposes and should be left unchanged.