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Community Agency Referral Request Form

The mission of Louisiana Multi-Agency Resource Center (LaMARC) is to improve public safety and minimize formal involvement in the juvenile justice system through early intervention, comprehensive assessment and coordinated access to appropriate services for underserved youth.

The LaMARC is a single entry point and coordinated approach to youth services that assists local systems of care in managing community resources efficiently and effectively in Lafayette Parish.

The LaMARC aims to offer timely, quality, and evidence-based services to all youth and families served. The LaMARC believes immediate intervention for youth provides the best outcomes for success. Referrals made to outside agencies must be willing to see LaMARC clients within a week of the referral. Agencies interested in providing services or receiving referrals to their organization from the LaMARC can fill out the below information.

Name of Agency

Type of Services Rendered

Evidenced-Based Services

Age Population Served

Where are Services Rendered

Program Contact & Title

Phone Number Format: 111-111-1111

Email Address

Hours of Operation

Insurances Accepted

Fee Charged to Client

Yes No

If yes, please specify:

Timeline for Services

Other Information (Please include information about waiting lists, length of services, criteria for services, referral process, etc.)

Agency understands that a partnership with the LaMARC requires services to be rendered in an expedited manner. Agency will provide a direct contact for the LaMARC and will communicate any delays, concerns, or progress.

Signature (Please type your first and lastname)

Date Format: mm/dd/yyyy