Referral Partners

This space is for schools, hospitals, social workers, or community agencies to learn how to refer families to Callan’s Legacy House. Please complete this form to refer a family for rental, mortgage, or housing assistance. A member of our team will follow up upon receipt of referral. If this is an urgent case, please complete the referral form and then contact us by phone or email to discuss further.

Referring Professional's Name

First Name

Last Name

Title/Position

Referring Organization

Phone

(###)

###

####

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Phone Number

(###)

###

####

Family Address if known

If unknown type "unknown"

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Language

Child's Name

First Name

Last Name

Child's Age

If unknown type 0

Primary Medical Diagnosis and Condition

If unknown type "unknown"

Housing Assistance Need

Behind on rent

Behind on mortgage

Recently evicted or at risk

Temporary housing/shelter

Unhoused

Need for hotel stay

General financial hardship due to medical crisis

Needing resources

How did you hear about us?

Any further information that would be pertinent and helpful

Confidentiality Acknowledgement and E-sign

I confirm that I have permission to refer this family or that this referral is based on publicly shared information for the purpose of connecting them with supportive services.

First Name

Last Name

Today's Date

YYYY

I agree

Yes, I agree that the above information is true and accurate to the best of my knowledge.

Referral Partners

Malone