Disaster Case Manager
Interest Form


What happens when I submit this form?
By filling out this form, you are requesting Disaster Case Management assistance from one of the agencies participating in the Los Angeles Region Long Term Recovery Group. Your request will be shared with a Disaster Case Manager from one of the agencies providing this service and you will be contacted for follow up only if you provide consent to share this information.

Why do I need to consent to share information? 
Disaster relief agencies, voluntary organizations and government agencies active in disaster recovery are committed to respecting your privacy. It is necessary at times for your Disaster Case Manager to share personal information gained during your partnership to coordinate and provide disaster relief assistance. Therefore, your consent to share and receive information for disaster-related services is necessary. By checking the box next to the statement below, you affirm the organization can share or receive your household’s information appropriately to advocate on your behalf and to avoid duplication of services.

If I have an urgent need, how can I get in touch with the Disaster Case Management team?
If you have an urgent needs, please don’t hesitate to call our dedicated DCM mailbox at (323) 800-2992‬.


 
Authorization *
Personal information
Name *
Name
Your street address at the time of the Woolsey Fire disaster *
Your street address at the time of the Woolsey Fire disaster
Your current street address (if different from above)
Your current street address (if different from above)
Contact phone number *
Contact phone number
Fire damages
Recovery assistance needs
Were you referred to this website by an organization offering Disaster Case Management Services for the Woolsey fire? *
If yes, would you like to partner with that agency for your recovery?
Are your living conditions safe, sanitary, and secure? *
Do you have income stability? *
Has the stress resulting from the disaster impacted your ability to work or perform daily tasks? *
FEMA number
Please enter all 9 digits.