English : Community Response Application : Central Navigation : Looking For Help : Douglas County Community Response

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.

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
D - Quite a lot like my life
E - Just like my life

Social Connections

I have people who believe in me. (Required)

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I have someone in my life who gives me advice, even when it’s hard to hear. (Required)

When I am trying to work on achieving a goal, I have friends who will support me. (Required)

When I need someone to look after my kids on short notice, I can find someone I trust. (Required)

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

Money/Bills/Budgeting
Relationships and/or My Love Life
Food/Nutrition
Stress, Anxiety, and/or Depression
Parenting/My Kids (if applicable)
None of the above

Concrete Supports

I was able to cover all my expenses last month (expenses include costs like rent, utility bills, food, transportation, child care, and medical expenses) (Required)

The transportation I use is reliable and consistent (Required)

My housing situation is affordable, safe, and stable (Required)

Over the past three months, my children and I have been able to see a doctor when we needed to. (If you do not have children, answer for just yourself) (Required)

Over the past three months, I have found a job and/or worked when I needed to (Required)

Community Response Participant Information:

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/Province *

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

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

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

Community Response Application

Community Response Pre-Survey:

Social Connections

Concrete Supports

Community Response Participant Information:

Looking For Help

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