Resource Navigator Appointment Request Form

Resource Advocate Appointment Request

Please complete this form to request an appointment with our Community Resource Advocate. You will be contacted as soon as possible once your request is received. We respond to requests in the order in which they are received. If you have difficulty completing this form, please call 501-318-1153 x108 or email advocacy@ccmchs.org. PLEASE NOTE: CCMC IS NOT AN EMERGENCY ASSISTANCE AGENCY. We will help you connect with Community Resources, help you develop a plan to stabilize, and provide follow up to help you keep on track. Cooperative Christian Ministries and Clinic Advocates work with you to collaborate, find solutions, resources, and a way forward. If we have assisted you, we cannot do so again for 12 months from the date of your last assistance. Receipt of this form does not guarantee that assistance or services will be received.
Today's Date

MonthDayYear
Date
Full Name*

First NameLast Name
Phone Number including Area Code*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
By providing your mobile number, you agree to receive text messages for reminders, confirmations, updates, inquiries, and responses to inquiries from CCMC. Message frequency varies as needed, and messaging and data rates may apply. You may opt out at any time by replying STOP. If you need assistance, please call 501-318-1153. We will not share your mobile information with any third parties. You can view our Privacy Policy and Terms & Conditions on our website https://ccmchs.org
Date of Birth*

MonthDayYear
Date
Last 4 Digits of your Social Security Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

FemaleMaleOtherPrefer not to answer
Are You Employed?*

Yes Full TimeYes Part TimeNoSearching for a Job
Who referred you or how did you hear about us?*
Household Monthly Income?*
Source of Income?*
Monthly Rent/Mortgage?
Monthly Utilities?
Monthly Transportation Costs (car payments, gas, bus, etc?)
Monthly Cable & Internet?
Monthly Insurance payments? (home, vehicle, health, etc.)
Monthly Food Expenses?
If you pay child support, what is your monthly payment?
Other monthly expenses (please describe)?
Do you receive SNAP? If yes, how much?
Briefly explain the need or situation you are currently experiencing:*
What are you needing help with today?*
How much is owed?*
When is it due?*
Please be prepared to provide a copy of your bill, lease, or agreement
Have you requested assistance with CCMC before?*

YesNo
If yes, what assistance did you receive and when?
What brought about your need for assistance? What has changed to cause this?*
What is your source of transportation?*

Personal vehicleGet rides from other peoplebusOther
Have you pursued assistance from other agencies within the past 12 months?*

YesNo
If yes, what agency or organization assisted you and how did they assist?
How do you plan to pay next month's bills?*
Number of People Living in Your Household?*
Number of Children Under Age 18 Living in Your Household?*
Current Housing Situation:*

RentOwnIn ShelterTemporarily Staying With OthersHomelessIn a Residential ProgramOther
Are you a resident of Garland County?*

YesNo
Do you have a good support system?*
Where does your closest relative live?
In order to assist you, we may need to contact other agencies, utilities, landlords, or others and share some of your information. We work diligently to protect confidential information, but there are times we need to share your information to connect you with the right community resources.
Do we have your permission to share relevant information in order to connect you with appropriate resources?*

YesNo
Do you certify that the information provided in this application is true and complete to the best of your knowledge?*

YesNo
Do you authorize CCMC to verify the information contained in this application?*

YesNo
When you come to your appointment, please bring copies of all documents we will need to verify your income (including child support), bills, rental agreement or rent receipt, ID, and other expenses that factor into your current situation. We will need to know your expenses for housing, utilities, food, gas/transportation, insurance, storage, and any benefits you receive (such as SNAP or Disability). We will contact you within 1-2 business days after we received this appointment request.
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Resource Advocate Appointment Request