Information and Referral Request Form

2. 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.
4. 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.
6. First Name*
7. Last Name
9. Primary Phone Number (10-digit)*
10. Email Address*
12. Preferred Method of Contact*

    1. Phone
    2. Email
14. Need Help With (select up to 2 services):*

    1. Affordable Housing
    2. Burial Assistance
    3. Child Services
    4. Clothing
    5. Daycare
    6. Dental
    7. Financial Counseling
    8. Finding a Job
    9. Food
    10. Fuel/Cooling/Crisis Assistance
    11. Home Repairs/Home Accessibility

    1. Homelessness/Eviction
    2. Immigration/Refugee Services
    3. Legal Assistance
    4. Medical Care
    5. Medical Insurance
    6. Nursing Home Care
    7. Transportation
    8. Paying for Prescriptions
    9. Rental Assistance
    10. Paying for Utilities
    11. Veteran Services
16. Please share additional information as desired:
Leave This Blank:


18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit Submit and Print

* indicates a required field