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Central Navigation Application

Fill out the following form to the best of your ability. Once you are finished, please submit and wait for a Central Navigator to contact you. If you have any questions, email Cathy Minnick at cminnick@central-plains.org or go to Contact Us.

 

1) How Can We Help?
What is your most urgent need? (Check all that apply)
2) Current Services and Supports
I am currently receiving the following services and supports: (Check all that apply)
I am currently receiving the following types of public assistance: (Check all that apply)
3) A Few Questions About You
First Name
Middle Initial/Name
Last Name
/
/
Country
Address Line 1
City
State
Postal Code
Is there someone who DOES NOT live with you we can contact if we cannot reach you?
If yes, please list the person's Name, Phone Number, and Relationship to You:
What is your gender?
What is your race/ethnicity? (Check all that apply)
If you chose 'American Indian or Alaskan Native', are you part of a federally recognized tribe?
Do you or your children QUALIFY for Medicaid, Title XX, and/or free and reduced lunch? (Even if you do not receive any of them):
Do you have a disability?
Do you have enough people to rely on when you need someone to give you good advice?
As of today, are you between the ages of 14 and 25? (Have not yet had your 26th birthday):
If you answered 'Yes' (ONLY if you are between the ages of 14 and 25), have you experienced any of the following?
Are you currently pregnant or expecting a child (mother or father)?
4) A Few Questions About Your Household
Do any of your children have a disability?

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