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Information and Referral Request Form
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This form has been modified since it was saved. Please review all fields before submitting.
Complete this form and a member of our Information & Referral staff will contact you by the next business day.
Our business hours are Monday-Friday, 8:30 a.m. – 5:00 p.m., excluding holidays.
Please DO NOT use this form to report a case of abuse, neglect or exploitation of a child, older adult, or adult living with a disability. Call the designated hotline as listed at:
loudoun.gov/humanservices.
First Name
*
Last Name
Primary Phone Number (10-digit)
*
Email Address
*
Preferred Method of Contact
*
Phone
Email
Need Help With (select up to 2 services):
*
Affordable Housing
Burial Assistance
Child Services
Clothing
Daycare
Dental
Financial Counseling
Finding a Job
Food
Fuel/Cooling/Crisis Assistance
Home Repairs/Home Accessibility
Homelessness/Eviction
Immigration/Refugee Services
Legal Assistance
Medical Care
Medical Insurance
Nursing Home Care
Transportation
Paying for Prescriptions
Rental Assistance
Paying for Utilities
Veteran Services
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