Please submit the form below to get in touch with a community liaison serving Marion County.
Required fields are marked with an asterisk *
Family/Parent(s) Name(s) *
Number of Children in home *
Address 1 *
Are you currently working with Healthy Families? * YesNo
Are you currently working with Child Protective Services? * YesNo
Are you currently working with Juvenile Probation System? * YesNo
Any bed bug issues? * YesNo
Please check the areas in which you would like more information or need assistance. * Basic Needs (food, housing, clothing)Child CarePregnancy/BirthSchoolTransportationUtilitiesHealth NeedsEmploymentMental HealthBudgetingSubstance AbuseParentingOther
How did you learn about us? *
Name of Referral Source:
If referred by a community resource, please fill out the lines below:
By submitting this online form, I authorize the release of the above stated information to Community Partners. I further understand that this is not an acceptance of services and that Community Partners has an ethical obligation to respect my right to privacy through the handling of information in a confidential manner. I further understand that a representative of Community Partners will contact me within five working days. By signing this form, I hereby consent to the release of the information above.