CHC Referral Form

Referral Form

Covenant House California (CHC) is a non-profit youth shelter that provides sanctuary and support for youth experiencing homelessness, ages 18-24. We believe that no young person deserves to be homeless; that every young person in California deserves shelter, food, clothing, education … and most importantly, to be loved. CHC provides a full continuum of services to meet the physical, emotional, educational, vocational, and spiritual well-being of young people, in order to provide them with the best chance for success in independence.
Location:

1325 N. Western Ave. Los Angeles, CA 90027
Outreach Number:

1-323-206-1096
CHC Outreach Team:

Anthony S., Cedric, Cat, Leslie and Anthony
Name of Agency/Volunteer referring:
Agency Point of Contact:
Agency/Volunteer:
Point of Contact Number:
Cilent's Name:

First NameLast Name
Nickname/Preferred Name
Date of Birth (00/00/0000):
Age:
Client's Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Client's Email:
example@example.com
Client's Emergency Contact (Friend,Family,etc.)
Please enter a valid phone number.Format: (000) 000-0000.
Case Manager (if working with another agency):
Gender
Race
Sexual Orientation
Please select the resources that will help support the client:
How did you find out about Covenant House CA?
What is the best way to reach you?
Is it okay to leave a voicemail on this number?
What language are you most comfortable with?

Other
What is your current living situation? (Are you sleeping Outside? In a car? With Friends or family? your own place? How much longer can you stay there?
Anything else that you would like to share?
Should be Empty:

Referral Form

Location:

Outreach Number:

CHC Outreach Team: