Community Action Program Intake Form

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.
Attention:

Community Action Program does NOT have rental, utility, or security deposit assistance available at this time.
Your Name*

First NameLast Name
Preferred Pronouns
Your Primary Language*

EnglishSpanishPolishChineseArabicOther
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / 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.)*

YesNo. 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 ManagementGovernment BenefitsReferralsBudgetingEmployment (resume building, interview skills, job searching, etc.)Housing (finding housing, eviction support, Section 8, etc.)Legal Services (child support, eviction, etc.)Educational Scholarship (for university, college, trade school, or occupational program)
How many people live in your household?*
How many adults live in your household?*
What is your housing situation?*

RentMortgageOwn (paid off)Homeless (on street, in vehicle, etc.)Homeless (couch surfing)Homeless (in shelter)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?*
Who is working in your household? What do you do for work?*
Do you have any income that is not from working? (select all that apply)*

Child supportAlimonySurvivor's benefitsDisabilityI do not have any household income that is not from working.Other
Is anyone in your household receiving government benefits? (select all that apply)*

Social Security Income (SSI)Social Security Disability Income (SSDI)UnemploymentFood Stamps (SNAP)Welfare or Temporary Assistance for Needy Families (TANF)Medicaid or Children's Health Insurance Program (CHIP)MedicareNo one is my household is receiving government benefits.Other
What agencies have you reached out to for assistance in the last 3 months?*

DeKalb TownshipSt. Vincent DePaulAssociation for Individual DevelopmentBen GordonCatholic CharitiesWestminster Presbyterian ChurchSalvation ArmyI 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 DevelopmentYes, Ben GordonYes, otherUnsureNo
Have you received services from Family Service Agency in the past or currently? (select all that apply)*

Yes, Children's Advocacy CenterYes, Youth Programming and/or School-Based ServicesYes, Center for CounselingYes, Senior ServicesYes, Community Action ProgramUnsureI have not received services from Family Service Agency.
How did you hear about Community Action Program?*

DeKalb TownshipCity of DeKalbHope HavenSt. Vincent DePaulSafe PassageEmployerGoogle/Search EngineFriend, Neighbor, or Family MemberOther
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?
To enroll in Community Action Program, please submit this form.

A Family Support Specialist, or case manager, will be in touch soon to discuss the next steps.
Should be Empty:

Community Action Program Intake Form

Attention:

To be eligible for this program you must provide proof of residency within DeKalb County, Illinois.

To enroll in Community Action Program, please submit this form.