Referral Form

Please complete the Housing Referral Form below and your information will be forwarded to the appropriate agency who can best provide services to you.  * = required information.

* In what area have you been sleeping for the past 30 days?
Danville City
Franklin County
Henry County
Martinsville City
Patrick County
Pittsylvania County
* What is your current living situation?
Doubled up with friends or family
Staying in a hotel/motel you can no longer afford
You have received a "Pay or Quit" notice from your landlord
You have received an Unlawful Detainer from the courts
Living someplace not meant for human habitation
Currently Fleeing Domestic Violence or Sexual Assault
Court ordered to leave within 14 days
None of the above apply
Do you have any current legal charges pending?
 Yes
 No
Have you been released from incarceration in the last 30 days?
 Yes
 No
* Number of people in your household?
 1     2     3+
* What is your Date Of Birth?
* What is your monthly household income?
$0 - 500
$501 - $1,200
$1,201 - $1,700
$1,701 - $2,200
$2,201 - $2,700
More than $2,700
If you were referred by an agency/program, please select the name of the agency/program below
* Myself or someone in my household is one of the following:
Veteran that does not have a dishonorable discharge
Has been diagnosed with HIV/Aids
Currently documented as having a Serious Mental Illness
Currently Fleeing From or a Victim of domestic violence or sexual assault
In need of space at a homeless shelter
I want legal advice about eviction paperwork I got from the court (Summons for Unlawful Detainer)
I need assistance obtaining a protective order
None of these apply to me or my household
Additional Information (100 characters max)
Your Name
*
*
Address
* Working Phone Number where you can be reached.
Is it safe to leave a message?
Yes    No
* Email Address
Please indicate your preferred language if other than English
By checking this box and submitting this online referral form, I am giving the West Piedmont Better Housing Coalition permission to share my information with agencies within the region to assist in securing housing services.