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- Are you a Delaware County Resident?*
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Format: (000) 000-0000.
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- Can we share your personal information with partners, if needed, in order to match you with services?
- Which days of the week are best to reach you if needed? (select all that apply)
- What times are best to reach you if needed? (select all that apply)
- Would you prefer a callback during business hours (M-F 8:30-4:30), or would you like to complete a 5-minute survey about your family’s needs? If you select callback, a DCHD staff person will contact you within two business days to complete a survey on the call in order to match your family with services and resources. If you select complete survey, you will receive a follow-up call ONLY if additional information is needed. Callback number: 484-724-4169.
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- Do you have any children 5 years old or younger?*
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- Do you have any worries about your children? Or do they have any special needs?*
- Are you pregnant?*
- When is your baby due?
- Is this your first pregnancy?
- Are you feeling stressed, sad, or overwhelmed during your pregnancy or while parenting and would you like support?*
- Do you have any concerns about substance use (such as alcohol, drugs, marijuana, or tobacco) by anyone in your immediate family?*
- Would you like support for this?*
- Parent: Are you 25 years old or younger?*
- Are you currently a student or enrolled in a High School equivalency program?*
- Parent: What is your Date of Birth?
- Do you have health insurance?*
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- Should be Empty: