Submit a Referral — Agape Housing Solutions

260-435-9881|6633 E. State Blvd STE 100, Fort Wayne, IN

For Professionals & Agencies

Case managers, hospitals, social workers, parole officers, and community agencies can use this form to refer individuals in need of safe, structured housing. We respond to all referrals promptly.

Hospitals & Medical Facilities

Case Managers & Social Workers

Parole & Probation Officers

Community Agencies & Nonprofits

Referral Form

Fields marked with * are required. For urgent placements, please call us directly at 260-435-9881.

Referring Party Information

First Name *

Last Name *

Organization / Agency *

Your Role / Title

Phone Number *

Email Address *

Referral Source *

Individual Being Referred

Client First Name *

Client Last Name *

Client Phone (if available)

Date of Birth

Population Type *

Housing Need / Urgency *

Current Location / Discharge Location

Additional Information

Special Needs or Considerations

Additional Notes

I confirm that I have authorization to share this individual's information with Agape Housing Solutions for the purpose of housing placement, and that the individual has been informed of this referral. *

For urgent or same-day placements, please call 260-435-9881 or fax to 260-818-2000.