Community Action Program Intake Form

Community Action Program Intake Form

Community Action Program provides a variety of services to individuals and families living with low income. 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 understand how challenging this time may be for you and want to reassure you that we are here to help as soon as possible. At this time, we have a seven-week waitlist. While you wait, we encourage you to contact 211 to explore additional resources that may provide support during this period. Please note that repeated inquiries about your application status will not affect your position on the waitlist.
Your Name*

First NameLast Name
Preferred Pronouns
Your Primary Language*

EnglishSpanishPolishChineseArabicOther
Phone Number*
Please enter a valid phone number.
Email
example@example.com
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.)
To be eligible for this program you must provide proof of residency within DeKalb County, Illinois.

Community Action does NOT require proof of US citizenship.
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.Unsure
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Financial Assistance

All financial assistance has been expended. Visit, https://fsadekalbcounty.org/financial-assistance/, for more information.
What services are you seeking? (select all that apply)*

Case ManagementEmployment (resume building, interview skills, job searching, etc.)Educational Assistance (scholarship, applying for FAFSA, etc.)Government BenefitsReferralsBudgetingTransportation Assistance (accessing the bus system, etc.)Housing (finding housing, applying for Section 8, etc.)Legal Services (expunging a criminal record, child support, eviction, etc.)
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?*

RentMortgageOwn (paid off)Homeless (on street, in vehicle, etc.)Homeless (couch surfing)Homeless (in shelter)Other
Do you have renters' insurance?*

YesNoUnsureOther
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 employedI am currently employed AND I'm seeking new employmentI am current unemployed AND I'm seeking employmentI am currently unemployed AND I'm NOT seeking employmentI am unable to workOther
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)*

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

Community Contacts (LIHEAP)DeKalb TownshipSafe PassageSt. Vincent DePaulAssociation for Individual DevelopmentBen Gordon CenterHope HavenCatholic CharitiesI 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.
What other FSA services would you like to learn more about? (select all that apply)*

Mental health counselingSupport groups for adultsSupport groups for youthYouth mentoringSenior ServicesNone of the aboveOther
How did you hear about Community Action Program?*

DeKalb TownshipCommunity Contacts (LIHEAP)City of DeKalbHope HavenSt. Vincent DePaulSafe PassageEmployerGoogle/Search EngineFriend, Neighbor, or Family MemberSocial MediaOther
Is there anything else you think we should know?
Waitlist

We understand how challenging this time may be for you and want to reassure you that we are here to help as soon as possible. At this time, we have a seven-week waitlist. While you wait, we encourage you to contact 211 to explore additional resources that may provide support during this period. Please note that repeated inquiries about your application status will not affect your position on the waitlist.
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.
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Community Action Program Intake Form

Waitlist

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

Financial Assistance

Waitlist

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