Information Services Request

In order for our office to provide you with the information you are looking for, please take a few minutes and complete this form and we will research based upon the information you provide services that will assist your household.

If you are in need of emergency financial assistance we can provide you with information to other programs that offer financial assistance by completing the bottom section of this form.

Question Title

* Please check all the resources you need assistance finding.

Nutrition

Employment

Transportation

Making Better Use of Available Income

Health Services

Education

Linkages to Other Programs

Self-Sufficiency

Affordable Housing Units

Income Management

Emergency Financial Assistance

Other (please specify)

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* This information is required if you would like to provide you with information and referral services. By answering the questions on this form we can identify programs you qualify for.

Your Name

Your Email Address

Your Phone Number

Your Address

Question Title

* Are you currently enrolled as a student?

Yes, full time in school

Yes, part time in school

Yes, full time on an undergraduate course

Yes, part time on an undergraduate course

Yes, full time on a postgraduate course

Yes, part time on a postgraduate course

No, I am not currently enrolled as a student

Yes, I am currently enrolled in a employment trainning program

Yes, I am currently enrolled in Building Brighter Futures Today

Yes, I am currently enrolled in Court Supervised Treatment Program

Question Title

* About how long have you lived in Park County, Wyoming?

Years

Months

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* How many people currently live in your household?

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* How many people living in your household are currently 60 years or older?

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* What is your approximate average household income?

$0-$24,999

$25,000-$49,999

$50,000-$74,999

$75,000-$99,999

$100,000-$124,999

$125,000-$149,999

$150,000-$174,999

$175,000-$199,999

$200,000 and up

Question Title

* Are your living quarters owned or being bought by you or someone in your household, rented for cash, or occupied without payment of cash rent?

Owned or being bought by you or someone in your household

Rented for cash

Occupied without payment of cash rent

Homeless

Other (please specify)

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* How many people in your household have health insurance?

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* How many people in your household are disabled?

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* How many services have been able to access services you found on our website?

more than 10

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* What information would you like to see our company provide?

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* How likely is it that you would recommend our website to a friend or colleague?

Not at all likely

Extremely likely

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* What type of device did you use to take this survey?

iOS Phone / Tablet

Android Phone / Tablet

Other Phone / Tablet

Windows Desktop / Laptop

MacOS Desktop / Laptop

Other (please specify)

Question Title

* Which of the following applies to your current situation?

Loss of Home-Due to fire or natural disaster

Domestic Abuse-Person fleeing a domestic abuse situation

Avoiding Homelessness-An individual, senior (60+), or family needing one-time assistance to avoid homelessness.

Elderly/Disabled/Homeless Health-Elderly (60+), disabled, homeless or disadvantaged individuals needing assistance with minor medical/dental.

Elderly/Disabled Home Repair or Basic Needs- Low income elderly needing funds to repair/modify home or purchase basic needs for home.

Funeral Expenses- support for funeral expenses for an immediate family member

None of these apply to me.

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* If you need emergency financial assistance was is the amount you are seeking?

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* Please provide us with a summary of your request, briefly explain your situation, and what resources are in place to ensure you will be able to resume payments next month.

Question Title

* Please check all the resources you need assistance finding.

Question Title

* This information is required if you would like to provide you with information and referral services. By answering the questions on this form we can identify programs you qualify for.

Question Title

* Are you currently enrolled as a student?

Question Title

* About how long have you lived in Park County, Wyoming?

Question Title

* How many people currently live in your household?

Question Title

* How many people living in your household are currently 60 years or older?

Question Title

* What is your approximate average household income?

Question Title

* Are your living quarters owned or being bought by you or someone in your household, rented for cash, or occupied without payment of cash rent?

Question Title

* How many people in your household have health insurance?

Question Title

* How many people in your household are disabled?

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* How many services have been able to access services you found on our website?

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* What information would you like to see our company provide?

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* How likely is it that you would recommend our website to a friend or colleague?

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* What type of device did you use to take this survey?

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* Which of the following applies to your current situation?

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* If you need emergency financial assistance was is the amount you are seeking?

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* Please provide us with a summary of your request, briefly explain your situation, and what resources are in place to ensure you will be able to resume payments next month.

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* What is your?

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* What is your current monthly income?

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* Does your household have a support system in place? Please explain.