MFH Digital Navigation Intake Form

  • Digital Navigator Intake Form

    2026

  • Thank you for reaching out to Media Fellowship House to learn more about our Digital Navigation services. We’re here to support you with accessing affordable internet options, low-cost computers, and digital literacy classes.

    Please take a moment to complete this brief form so we can better understand your current technology needs and connect you with the right resources.

  • Format: (000) 000-0000.
  • Have you worked with Media Fellowship House previously?*
  • How did you learn about our services?*
  • What is your age group?
  • Race/Ethnicity
  • Gender
  • Do You Need a Language Interpreter?*
  • Are there school-age (Kindergarten through 12th grade) children in your household?
  • Do you or someone in your household receive government benefits (such as SNAP, Medicaid, TANF, Public Housing Assistance, National School Lunch Program, or LIHEAP) and/or have a total gross household income that is less than 80% of the Area Median Income (AMI)?.

  • Family Size | Household Income Limit

    1 $64.250
    2 $73,400
    3 $82,600
    4 $91,750
    5 $99,100
    6 $106,450
    7 $113,800
    8 $121,150

    *NOTE: Media Fellowship House seeks to support low and moderate income households in Delaware County. Digital navigation services are not limited to this guideline, but we collect this information for our funding partners to measure their outreach goals.

  • Do you currently have access to the internet at home?*
  • Do you currently have a mobile phone (smart phone) with internet capability?*
  • Do you currently have a (working) laptop or desktop computer?*
  • What type(s) of digital support are you looking for?*
  • Are you interested in any of the following housing counseling services at MFH?

  • I understand that funders provide grants to make the digital navigation services possible, and that Media Fellowship House shares my information with these funders.

    By typing my name into this form below I agree to share my information included within this intake application. All information is stored securely and kept confidential between Media Fellowship House and the grant funder. 

    The following is the grant funder for this digital navigation program: United Way of Greater Philadelphia and Southern New Jersey.

  • Digital Navigator post-appointment survey:

  • Successfully helped to complete a specific online task?
  • Successfully connected with a mobile/smart phone with internet capability?
  • Successfully connected with a computer (desktop, laptop, tablet)?
  • Successfully connected to the Internet?
  • Successfully referred to / enrolled in another digital literacy / adult education program?
  • Status
  • Date of closed ticket
     - -
  • Should be Empty: