MFH Digital Navigation Intake Form

Digital Navigator Intake Form

2025
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.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Have you worked with Media Fellowship House previously?*

YesNo
How did you learn about our services?*

211Email or FlyerMedia Fellowship HouseSurrey Senior Services - BroomallSurrey Senior Services - MediaUnited WayOutside Agency ReferralPennsylvania Institute of TechnologyOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your age group?*

17 or younger18-2425-3435-4445-6060+
Race/Ethnicity*

American Indian/Alaska Native/Native American/IndigenousArab/Middle Eastern AmericanAsian American/Pacific IslanderBlack/African AmericanHispanic/Latino/a/e/xTwo or More RacesWhite/CaucasianPrefer Not to Answer
Gender*

FemaleMalePrefer Not to AnswerOther
Do You Need a Language Interpreter?*

NoYes
Preferred Language*
Are there school-age (Kindergarten through 12th grade) children in your household?*

NoYes
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)?.*

NoYesPrefer Not to Answer

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?*

YesNo
Do you currently have a mobile phone (smart phone) with internet capability?*

YesNo
Do you currently have a (working) laptop or desktop computer?*

YesNo
What type(s) of digital support are you looking for?*

Help signing up for affordable internet serviceAssistance applying for a low-cost or refurbished computerLearning how to use a computer, smartphone, or tabletSetting up and using emailNavigating websites or using online services (e.g., banking, job applications, government benefits)Help with video calls (Zoom, Google Meet, FaceTime, etc.)Accessing or using educational tools or learning platformsSupport with online safety and protecting personal informationConnecting a printer, camera, or other devicesOther (please describe below)
Is there anything else you’d like to share about your technology needs or goals?
Are you interested in any of the following housing counseling services at MFH?

First Time Homebuyer Education & GrantsForeclosure Prevention CounselingHousing Stability CounselingBudget & Credit CounselingUtility AssistanceNo, not at this time
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.
Name*

First NameLast Name
Digital Navigator post-appointment survey:
Successfully helped to complete a specific online task?

YesNo
Successfully connected with a mobile/smart phone with internet capability?

NoYes
Successfully connected with a computer (desktop, laptop, tablet)?

NoYes
Successfully connected to the Internet?

NoYes
Enroll in Northstar or a similar assessment?

No
Donated Device Serial #, Description and Source
If applicable
Receive a Northstar or similar certificate?

No
Successfully referred to / enrolled in another digital literacy / adult education program?

NoYes
Status

SuccessfulIn ProgressClosed
Date of closed ticket

MonthDayYear
Case Notes
Should be Empty:

Digital Navigator Intake Form

Family Size | Household Income Limit

Digital Navigator post-appointment survey: