Make a Referral

Client Information

Is the client currently living in Allegheny County, and do they fall into one of these categories: 1) Immigrants, 2) Children of immigrants, 3) Individuals from US territories, 4) US citizens born and raised outside of the continental states?*

Yes
No

ISAC can only serve individuals who reside in Allegheny County with a language or cultural barrier who fall into one of the following categories: immigrants, children of immigrants, individuals from US territories, US citizens born and raised outside of the continental United States.

Those who do not meet these requirements should call United Way at 2-1-1 or the Community COVID Hotline at 412-422-0400 to be directed to the appropriate services.

I received permission from the client to submit this referral*

Yes
No

Please note that we cannot contact the client if they did not give permission for this referral.

Is the client in need of immigration legal services ONLY?*

Yes
No

If the client is seeking immigration legal assistance ONLY, please fill out this form for JFCS Immigration Legal Services Department. Click here for form.

If the client needs additional services, please check "No" in the box above and complete the referral.

Name*

If the person that needs assistance is under 18 please provide the parent or guardians information.

First Middle Last

Phone Number*

Other Phone Number

Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Country Of Origin (Place Of Birth)*

Language(s) Spoken*

Does the client need interpretation? (Please only select one answer)*

Yes
No

What language does client need interpreted?*

Reason for Referral & other relevant information. Please be specific and describe what services or resources the client needs connected to and any barriers experienced in doing so: (Ex: Client needs urgent medical care, client does not has food at home, etc)*

Referral Source*

Please explain who the referring party is - whether it is a provider, self-referral, family or friend.

Self-Referral
Friend, Family or Community Member
Organizations or Providers

Self-Referral, Family, Friend or Community Member

Name*

First Last

Phone Number*

Email

Organization

Name*

First Last

Organization*

Phone Number*

Job Title*

Email*

What support and services have you provided to this client? Did you refer the client to any other agency? If yes, please list them.*

What services are you unable to provide and why?*

Name

This field is for validation purposes and should be left unchanged.

We will communicate with you in your language.

Make a Referral

Client Information

Self-Referral, Family, Friend or Community Member

Organization

Please note, the client will receive a call back in the order referrals are received unless referral is indicated as an emergency. Referring parties will not be contacted unless further information is needed.

ISAC Partners

We welcome your feedback. Contact the Directors Action Line with questions, concerns, complaints or comments about any service we provide.

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