Housing Support Request Form
Organization/Recommender
Email address
(to which our reply will be sent)
Name of Client
Phone
DOC/Reg. Number
Ethnic Background
African American
Hispanic
Caucasian/White
Asian
Indian
Other
Demographics
Woman
Man
LGBTQI
Trans Man
Trans Woman
I mainly identify with the population of:
To be consider for ROSC Placement, you must respond to the appropriate population. Check all that applies.
Woman
Veteran
LGBTQI
Registry Individual
Mentally Disadvantged/Addictive Disorders
Youth with challenges
HIV/AIDS
Other
Current Address
Please list your full street address, name, city and state where you are located.
Message
Please describe in detail your support request, LGBTQI, please specify your assignment at birth for proper placement.
Today's Date
LaCOR Email DO NOT TOUCH
Submit the Support Form