Woolsey Fire
Disaster Case Manager
Interest Form

Authorization *

I authorize the Los Angeles Region Long Term Recovery Group to share my information with agencies providing disaster case management services in order to receive contact from a Disaster Case Manager. I further authorize my disaster case management organization to share and receive my personal information, including, but not limited to, name, address, assistance received for disaster recovery, in order to coordinate available partner resources and services and advocate on my behalf for purposes of the Woolsey Fire disaster recovery.

Woolsey Fire survivor *

I am a Woolsey Fire survivor.

Name *

First Name

Last Name

Your street address at the time of the Woolsey Fire disaster *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your current street address (if different from above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact phone number *

(###)

###

####

Were you referred to this website by an organization offering Disaster Case Management Services for the Woolsey fire? *

Yes

No

I'm not sure

If yes, would you like to partner with that agency for your recovery?

Yes

No

I'm not sure

Are your living conditions safe, sanitary, and secure? *

Yes

No

Do you have income stability? *

Yes

No

Has the stress resulting from the disaster impacted your ability to work or perform daily tasks? *

Yes

No