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Esperanza Online Appointment Form
We’re glad you’re here, and we look forward to supporting you and your family! Appointments may be scheduled once per month. If you live in Corpus Christi or Robstown, please visit our office or meet us at one of our Hope’s Closets for assistance, as curbside orders are not available for residents of these communities. Each order we prepare has a maximum value of $25 so we can help more families with the resources available. Please make arrangements to pick up your order. If it is not picked up, we will be unable to prepare another order for you. Thank you for helping us make these resources available to our community!
Please select the type of appointment request
Please Select
Emergency Aid
Resource Navigation
Application Assistance
Virtual Case Management
Corpus Christi Resource Center
Robstown Hope's Closet
Name
*
First Name
Last Name
Age
*
Please Select
14-17
18-21
22-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66-70
71-75
76-80
81-85
86-90
91-95
96-100
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Zipcode
*
Select the county you reside in within our service area
*
Please Select
Aransas
Bee
Bexar
Brooks
Calhoun
Cameron
DeWitt
Dimmit
Duval
Goliad
Harris
Hidalgo
Jim Hogg
Jim Wells
Karnes
Kenedy
Kleberg
La Salle
Live Oak
Maverick
McMullen
Nueces
Refugio
San Patricio
Starr
Victoria
Webb
Willacy
Zapata
Does anyone in your household receive any of the following:
*
Please Select
Housing Assistance
SNAP
WIC
ECI
Head Start Program
SSI/SSID
TANF
Medicaid
Medicare
CHIP- Children's Medicaid
My family does not receive assistance
How many people reside in your home?
*
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
How many are under the age of 18?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
12
How many are over the age of 18?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
12
Are you or anyone in your household insured?
*
Please Select
Yes
No
Unsure
What type of insurance do you have?
*
Please Select
I am uninsured
Traditional Texas Medicaid
STAR Medicaid
STAR+PLUS Medicaid
STAR Kids Medicaid
STAR Health Medicaid
Aetna Better Health of Texas
Blue Cross and Blue Shield of Texas
Community First Health Plans
Community Health Choice
Driscoll Health Plan
Molina Healthcare of Texas
Superior HealthPlan
Texas Children’s Health Plan
UnitedHealthcare Community Plan
Wellpoint
CHIP
CHIP Perinatal
Aetna Better Health of Texas CHIP
Community First Health Plans CHIP
Community Health Choice CHIP
Driscoll Health Plan CHIP
Molina Healthcare CHIP
Superior HealthPlan CHIP
Texas Children’s Health Plan CHIP
UnitedHealthcare CHIP
Wellpoint CHIP
Original Medicare Part A
Original Medicare Part B
Medicare Advantage, Part C
Medicare prescription drug plans, Part D
Medicare Supplement insurance, Medigap
Dual Eligible Special Needs Plans, D-SNP
Chronic Condition Special Needs Plans, C-SNP
Institutional Special Needs Plans, I-SNP
Ambetter from Superior HealthPlan
Ambetter Health / Celtic Insurance Company
Baylor Scott & White Health Plan
CHRISTUS Health Plan
Cigna Healthcare
Community First Insurance Plans
Imperial Insurance Companies
Moda Health
Molina Healthcare
Oscar Health
UnitedHealthcare
Aetna
Surest
HealthSelect of Texas
Consumer Directed HealthSelect
TRS-ActiveCare
TRS-Care
TRICARE
CHAMPVA
VA health care benefits
Are you in need of a referral for any of the following? Please select all that apply:
*
Please Select
I do not need any referrals
Domestic Violence Assistance
Housing Assistance
Food Assistance
Clothing Assistance
Childcare Assistance
Medicaid/CHIP- Renewal
Continuing Education-GED
Internet Access
Transportation Assistance
Utilities Assistance
Emotional Parent Support
Healthcare Access
Mental Health Access
What is your employment status?
*
Please Select
Full Time
Part Time
Self Employed
Not Working
Retired
What is your current housing situation?
*
Please Select
Staying with Family/Friends
Unhoused, staying in shelter
Unhoused, staying on street
Rent
Own
Are you in need of essential items?
*
Please Select
Yes
No
Unsure
Are you making the appointment for yourself or someone else?
*
Myself
Client
Who referred you to us?
*
Appointment
*
Submit
Should be Empty: