Case worker / agent referral

Submit a referral

For case workers, social workers, hospital discharge planners, reentry coordinators, and other referring agents. Information is confidential and only shared with vetted housing providers after admin review.

Applicant

Who is completing this form? *

First name *

Last initial *

Phone

Age

Gender

Household type *

Household size (people)

Housing need

County *

Specific city / area (optional)

Bedrooms / unit *

Room preference

Urgency *

Move-in timeframe

Financial

Monthly income ($)

Income source

Voucher / assistance

Monthly housing budget — including utilities ($)

Background & accessibility

Accessibility needs

Criminal history (optional)

Eviction history (optional)

Recovery / reentry context (optional)

Anything else we should know

Referring agent / case worker

Your name *

Agency / organization *

Your email *

Your phone

All information submitted is held confidential by DALS, LLC. Identifying information may be shared with vetted housing providers for housing placement purposes only.

I consent to DALS sharing this information with vetted housing providers for the purpose of housing placement.I certify the information above is true and accurate to the best of my knowledge and I have the applicant's permission to submit it.