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Community Response Application

REMINDER: 

***Please be advised that financial assistance through Central Navigation was paused on October 11th, 2021. We will follow up with you regarding your application approval/denial. Going forward, we will be unable to process applications for financial assistance until the first of the year.

At this time, we are working with other community resources to meet housing and utility needs through the end of the year.  As a part of Central Navigation, we will conduct a thorough search of local resources based upon the applications we receive from either the website or your organization. For additional supports, such as transportation and concrete support (clothing, daily living/hygiene, food, etc.), Central Navigation will continue to guide families through program requirements and coaching opportunities. For general updates and community resources, please keep checking our website and Facebook page.  ***

 


 

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. To receive help from Central Navigation you: 

  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)
Country
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?

**MAKE SURE YOU HAVE FILLED OUT THE ENTIRE APPLICATION BEFORE SUBMITTING**