Please note: This form is secure and any information submitted will remain confidential.
PLEASE NOTE: This form is only for DSA referrals in the Eugene/Springfield area.
If you are seeking DSA on the coast, please use the Oregon Coast DSA referral form.
(These referrals are on pause as of 2/20/2024)
If you are also seeking attendant care supports, please use the Attendant Care referral form.