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Community Action Program Intake Form
Community Action Program provides a variety of services to low-income individuals and families. Every service plan looks different for every family, but our goal is to raise people out of poverty through empowerment, hope, and education.
Waitlist
We truly understand how difficult this time may be for you and want to assure you that we are here to help as soon as we can. While we currently have a four-week waitlist and will be in touch before February 1st, we encourage you to contact 211 in the meantime to connect with other resources that may provide support during this challenging time.
Your Name
*
First Name
Last Name
Preferred Pronouns
Your Primary Language
*
English
Spanish
Polish
Chinese
Arabic
Other
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
To be eligible for this program you must provide proof of residency within DeKalb County, Illinois.
Can you provide documented proof of residency within DeKalb County, ILLINOIS? (government issued ID, lease, mortgage, utility bill, bank statement, benefits letter, shelter placement, etc.)
*
Yes
No. You are ineligible for services if you cannot provide proof of DeKalb County, Illinois residency.
Unsure
What services are you seeking? (select all that apply)
*
Case Management
Employment (resume building, interview skills, job searching, etc.)
Educational Assistance (scholarship, applying for FAFSA, etc.)
Government Benefits
Referrals
Budgeting
Supplies for Work (clothing, tools, hygiene products, etc.)
Vehicle Assistance
Housing (finding housing, eviction support, Section 8, etc.)
Legal Services (child support, eviction, etc.)
Utility Assistance
Please provide a brief explanation about why you're seeking services
*
How many people live in your household?
*
How many adults live in your household?
*
What is your housing situation?
*
Rent
Mortgage
Own (paid off)
Homeless (on street, in vehicle, etc.)
Homeless (couch surfing)
Homeless (in shelter)
Other
Do you have renters' insurance?
*
Yes
No
Unsure
Other
If you rent, who is listed on your lease?
If you rent, who is your property manager/landlord?
What is your estimated monthly household income?
*
Select the option that best describes your situation....
*
I am currently employed
I am currently employed AND I'm seeking new employment
I am current unemployed AND I'm seeking employment
I am currently unemployed AND I'm NOT seeking employment
I am unable to work
Other
Do you have any income that is not from working? (select all that apply)
*
Child support
Alimony
Survivor's benefits
Disability
I do not have any household income that is not from working.
Other
Is anyone in your household receiving government benefits? (select all that apply)
*
Medicaid or Children's Health Insurance Program (CHIP)
Food Stamps (SNAP)
Welfare or Temporary Assistance for Needy Families (TANF)
Unemployment
Social Security Income (SSI)
Social Security Disability Income (SSDI)
Medicare
No one is my household is receiving government benefits.
Other
What agencies have you reached out to for assistance in the last 3 months?
*
DeKalb Township
St. Vincent DePaul
Association for Individual Development
Ben Gordon
Catholic Charities
Salvation Army
I have not reached out to any other agencies for assistance in the last 3 months.
Other
Are you currently receiving case management services from any other organization?
*
Yes, Association for Individual Development
Yes, Ben Gordon
Yes, other
Unsure
No
Have you received services from Family Service Agency in the past or currently? (select all that apply)
*
Yes, Children's Advocacy Center
Yes, Youth Programming and/or School-Based Services
Yes, Center for Counseling
Yes, Senior Services
Yes, Community Action Program
Unsure
I have not received services from Family Service Agency.
How did you hear about Community Action Program?
*
DeKalb Township
City of DeKalb
Hope Haven
St. Vincent DePaul
Safe Passage
Employer
Google/Search Engine
Friend, Neighbor, or Family Member
Other
Safety Considerations, is there anything we should know to help keep you safe? (examples: don't call after 3:00pm, prefer to communicate via email, etc.)
Is there anything else you think we should know?
Waitlist
We truly understand how difficult this time may be for you and want to assure you that we are here to help as soon as we can. While we currently have a four-week waitlist and will be in touch before February 1st, we encourage you to contact 211 in the meantime to connect with other resources that may provide support during this challenging time.
To enroll in Community Action Program, please submit this form.
A Family Support Specialist, or case manager, will be in touch to discuss the next steps.
Submit
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