Douglas County Community Response : Douglas County Resources : Family : CR/CYI Participant Information Form

All parts of the Participant Information Form should be completed at the start of participation in Community Response or the Connected Youth Initiative. The form may be completed with the assistance of a Central Navigator or other service provider, if needed. You may fill out the form online below, or download the fillable pdf version.

Your preferred name (Required)

Your preferred pronouns

What is your most urgent need? Check all that apply

Is there anything else you need us to know?

I am currently receiving the following services and supports (check all that apply)

I am currently receiving the following types of public assistance (check all that apply)

Full LEGAL Name (first, middle, last) (Required)

Phone number (Required)

Email (Required)

Address

Country

Address Line 1

City

State

Postal Code

Date of birth (Required)

Is there someone who doesn’t live with you we can contact if we can’t reach you?

If yes, please list the person's name, phone number, and relationship to you

What is your gender?

Male
Female
Another gender
Prefer not to answer

What is your race/ethnicity? (check all that apply)

White
Black or African American
Hispanic or Latino
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaskan Native
Other race or ethnicity
Prefer not to answer

If Native American or Alaskan Native, are you part of a federally recognized tribe?

Do you or your children QUALIFY for Medicaid, Title XX, and/or free and reduced lunch, even if you don’t receive any of them?

Yes
No
Unsure
Prefer not to answer

Do you have a disability?

Yes
No
Prefer not to answer

Do you have enough people to count on when you need someone to give you good advice?

Yes
No
Prefer not to answer

If yes, how many people can you count on? (write number).

As of today’s date are you between the ages of 14 and 25 (have not yet had your 26th birthday)?

ONLY if you are between the ages of 14 and 25 (answered “yes” to above), have you experienced any of the following?

Foster care/state ward/placed outside of the home
In-home services for your family (from DHHS)
Guardianship or Adoption
Probation or Incarceration
Homelessness
Human Trafficking
Prefer not to say
N/A, no experience with any of these

Are you currently pregnant or expecting a child (mother or father)?

Yes
No
Prefer not to answer

Including yourself, how many ADULTS (people 18+) are in your household? (Required)

How many CHILDREN (people 17 and younger) are in your household? Enter 0 if no children live with you (Required)

Do any of your children have a disability?

Yes
No
Prefer not to answer

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If yes, how many of your children have a disability? (write in number)

CR/CYI Participant Information Form

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