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City of Euclid, Ohio

585 E 222nd St, Euclid, OH, United States

216-289-2700

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Shore Cultural

Referral for Social Services

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This form is for agencies looking to make a referral to the Euclid Neighborhood Center.

Are you a resident or community partner looking to make a referral to help someone find services? PLEASE CLICK HERE.

Community / Self Referral Form

Date of Referral:

Referrering Agency:

Referral Contact Name:

Referral Contact Title:

Referral Contact Phone Number:

Name:

Phone Number:

Street Address:

City:

Zip Code:

Last 4 Digits SSN:

Does the resident being connected currently have child(ren) under 18 years old?

YES

NO

N/A

Is the resident being connected currently involved with DCFS?

YES

NO

N/A

Is the resident being connected currently 65 or older?

YES

NO

Household Member #1 Name:

Household Member #1 Date of Birth:

Household Member #1 Relationship:

Household Member #2 Name:

Household Member #2 Date of Birth:

Household Member #2 Relationship:

Household Member #3 Name:

Household Member #3 Date of Birth:

Household Member #3 Relationship:

Household Member #4 Name:

Household Member #4 Date of Birth:

Household Member #4 Relationship:

Household Member #5 Name:

Household Member #5 Date of Birth:

Household Member #5 Relationship:

Relationship to Child(ren):

Parent

Legal Guardian

Foster / Adoptive Parent

Other

Brief Statement of Need:

I acknowledge and understand that by submitting this referral form, I am providing the information to the Euclid Neighborhood Center and all affiliated entities as part of their effort to provide human services to the resident in need. I agree that all the information I have provided is accurate and truthful to the best of my knowledge.

YES

Thank you for reaching out for assistance for someone you care about in the Euclid Community. Our team is committed to identifying local services for Euclid families. We will follow up with you within 48 hours

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CONTACT US

Euclid City Hall
585 East 222nd St.
Euclid, Ohio 44123

Phone Number:
216-289-2700

CONNECT WITH US

To Report a Problem, Request Information or Request Service

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