Connected Community Schools Request for Assistance
Connected Community Schools Leaders in Network Knowledge, or LiNK, is here to help serve as a ConnectLine between you and whatever services or assistance you need. If you or your family is struggling and would like to talk to one of our Connected Community resource experts, fill out this self-referral form and we'll get in touch to help make these Connections any way we can!

*Please note - this form must be completed by someone 18 years of age or older. This form is also not for emergencies - if you or someone you know is in a crisis situation/in need of emergency assistance, please call 911.
Email *
Name and DOB *
"John Smith, 12/31/1975"
Address *
County *
(select all that apply)
School District *
Phone Number (###-###-####) *
Preferred Time of Contact *
Best way to reach you with questions regarding this form
Area(s) of Concern/Need *
Select all that apply
Please provide a summary of what you would like assistance with: *
Do you have insurance? *
If yes, do you have medicaid? *
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This form was created inside of Connected Community Schools.