If you are in need of health and human service assistance as a result of coronavirus (COVID-19), please complete the form below or call 2-1-1.

Filling out this assistance request form means you’re asking to be connected to a service provider in your area who’s able to meet a social or medical need that you or someone in your care may have. Once completed, this form is sent to the coordination center and a licensed social worker will contact you as soon as possible. We will do our best to connect you with services in your area if they are available. The information you enter is completely confidential and there is no cost for this service.

Please use this form only to request services for yourself or a child (under 18 years old) or adult for whom you have legal guardianship. Consent submitted through this form should be signed by the person who would be receiving services or by their parent or legal guardian only.