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Community Response Application


INSTRUCTIONS: 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.

Eligibility Requirements:

  1. Must be a resident of Douglas County
  2. Must be pregnant or parenting a child from ages 0-17 
  3. Cannot have any open CPS cases
  4. Must have required documentation specified below
Community Response Pre-Survey:

For each of the following, mark the response that most closely matches how you feel:

A - Not at all like my life
B - Not much like my life
C - Somewhat like my life
- Quite a lot like my life
E - Just like my life

Social Connections

I have people I trust to ask for advice about (check all that apply)

Concrete Supports



Community Response Participant Information:
What is your most urgent need? Check all that apply
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)
Address Line 1 *
City *
State/Province *
Postal Code *
Is there someone who doesn’t live with you we can contact if we can’t reach you?
What is your gender?
What is your race/ethnicity? (check all that apply)
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?
Do you have a disability?
Do you have enough people to count on when you need someone to give you good advice?
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?
Are you currently pregnant or expecting a child (mother or father)?
Do any of your children have a disability?