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Today's Date
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Check your most important needs below
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Current services and supports
I am currently receiving the following services and supports
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I am currently receiving the following types of public assistance
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A few questions about you…
Is there someone who doesn’t live with you we can contact if we can’t reach you?

If yes, please list the person’s:

Did you move here from another state?
What is your gender?
What is your race/ethnicity?
(check all that apply)
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 don’t receive any of them?
Do you have a disability?
Do you have enough people to count on when you need someone to give you good advice?
If yes, how many?
As of today’s date are you between the ages of 14 and 25 (have not yet had your 26th birthday)?

ONLY if you are between the ages of 14 and 25 (answered “yes” to above), have you experienced any of the following?

Are you currently pregnant or expecting a child (mother or father)?
Are you currently a parent or caring for a child (for example, foster parent, grandparent, aunt)

if you are currently a parent or caring for a child (answered “yes” to above) please also complete the next section.

A few questions about your children…

If you do not currently have any children, you do not need to complete this section

Number of children in household under 18 (enter 0 if no children live with you)
Do any of your children have a disability?
If yes, how many?
Authorization to Share Your Information (Consent)

The following information is collected as part of the CR/CYI EVALUATION

  • You and/or your child(ren)’s basic information
  • Demographic Information
  • Current Services & Supports

The following items as applicable

  • Support Services Fund Application Form
  • Survey responses to the following 
       -  Community Response Coaching Survey
       -  Transitional Services Survey

The following information will be shared with other provider partners in the community for SERVICE PROVISION

  • Your Name
  • Your contact information
  • Other relevant information on this

Participant Information Form that may help other agencies provide you services

MARK THE BOX(ES) BELOW IF YOU AGREE. You can mark both boxes, one box, or neither.

SHARE MY INFORMATION FOR EVALUATION.

Check if you agree

I hereby grant permission for the local Community Well Being coordinator and/or necessary staff and the (CR/CYI Agency or agencies) to share my information with Nebraska Children and their contracted evaluators including Munroe‐Meyer Institute, as part of the EVALUATION of this program that is funded in part by Nebraska Children. You are participating in a Community Response that is sponsored by CWCC which is a federally funded grant. This is to inform you that we will be asking you to complete surveys are part of the evaluation, which is being completed by Munroe‐Meyer Institute at the University of Nebraska Medical Center. Information from this evaluation may help the program better support families in similar programs. Your name will not be included in any of the information that you provide us. All data collected will only be summarized as a group. No individual responses will be reported. If you have any questions about this research project, please call Dr. Barbara Jackson at 402‐559‐5765. You are not required to share this information. If you decide not to have this information shared, it will not affect you or your standing in our program in any way. For evaluation reporting purposes, your information will always be combined and will not be identifiable at the individual family level.

SHARE MY INFORMATION FOR SERVICE PROVISION.

Check if you agree

I hereby grant permission for the local Community Well Being coordinator and/or necessary staff and the CR/CYI Agency or agencies to share my information with other partnering agencies to assist in PROVIDING ME OR MY FAMILY WITH SERVICES. I understand that if I do not mark this box, I will be responsible for reaching out to other partner organizations for further assistance on my own time.

If you have questions about the evaluation, please contact Barbara Jackson at Munroe‐Meyer Institute at 402‐559‐5765 or Catherine Brown at Nebraska Children and Families Foundation at 402‐302‐1588.

Review and Submit

If you are a minor, you must fill out the PDF Referral Form and submit to Brittney Livingston.