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!

If you are a case manager/worker filling this out for a client, please ensure they have provided verbal permission for us to reach out first. Please indicate if the contact information provided is for you or for the client.

*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.
Sign in to Google to save your progress. Learn more
Email *
Name and DOB *
"John Smith, 12/31/1975"
Address *
County *
Does anyone in your home attend/belong to a school district?
Clear selection
Please select your school district (if no one in your home attends school just select the school district you live in.) *
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
Required
Please provide a summary of what you would like assistance with: *
If the children in the home are in school, please state the name of the school(s) they attend.
Do you have insurance? *
If yes, do you have medicaid? *
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Connected Community Schools.