100 Families Initiative of North Pulaski Family Referral Form
100 Families Initiative of North Pulaski County helps to move families from a place of crisis to an environment where they are thriving. This includes connecting families with children to the various resources in their community in areas such as housing, transportation, employment, education, addiction/recovery, food stability, education and more. Our office serves families located in and around North Pulaski County including but not limited to the cities of North Little Rock, Maumelle, Jacksonville. 

Our office is located within the Every Arkansan/Arkansas Dream Center offices located at 1900 Pine Street, North Little Rock, AR 72114. Please inform all families to utilize Google Maps when trying to locate our physical address (Link: https://g.co/kgs/KhB8vtx). Other mapping services will get you lost. 

If you have any questions regarding the completion of this form or our program please feel free to call our office at 501-351-0476 or you can email our coordinator Deanna Walderns at deanna@everyarkansan.org.
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Email *
Referral Type *
Referring Organization Information (SKIP FOR SELF REFERRAL)
Referring Organization Name
Referring Contact Name
Referring Phone Number
Referring Email Address
Would you (referring organization) like to be contacted once we reach the family and make an assessment appointment?
Clear selection
Are you part of the 100 Families Alliance?
Parent/Guardian Information 
Parent/Guardian First Name *
Parent/Guardian Last Name *
Phone Number *
Email Address
Last 4 digits of Guardian Social Security Number
Address
City
State
Zip Code
Referral Questionnaire 
The 100 Families Initiative of North Pulaski County is grant funded and currently only available to families with children under the age of 18. Please answer as many questions as possible.
What person/organization referred you to 100 Families?
Do you/client have children under the age of 18? *
How many children do you have? *
What resource areas are you hoping 100 Families can assist you with? (Check all that apply) *
Required
Do you currently receive any of the following benefits?
Do you have an open protective or supportive service child welfare case with the Division of Children and Family Services (DCFS)?
Clear selection
If YES, who is your case worker??
Are you on probation or parole?
Clear selection
If YES, who is your officer?
Is there anything else you would like us to know?
Thank you a family advocate will be in contact with you/ the referred family.
One of our family advocates will connect with you as soon as possible to schedule an intake assessment. In the first appointment, a family advocate will be doing an intake that addresses many areas to see what community resources we can connect you with. A family advocate will work with you to complete an action plan to help you meet your goals. 
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