*
First Name Last Name
Preferred Name
Date of Birth*
MM slash DD slash YYYY
Your Phone Number*
Your Email
County*
Thank you for reaching out to the Care Connect+ General Navigation program. At this time, we do not have community partners in your location to meet the needs that you have expressed. We are excited to expand our services and look forward to the time when we will be able to partner with services providers to meet these needs.

Until that time, your best option to learn about resources in your community may be by calling 2-1-1.
Your Address*
Street Address Address Line 2 City State ZIP Code
If you are currently homeless, please put "Homeless" in the Street Address field above.

Gender*
Are you pregnant*
- Yes
- No
Race*
Ethnicity*
Are you a veteran?*
What is your marital status?*
Do you have any outstanding tickets or warrants?*
Do you have any current court charges or on probation/parole?*
What is your current living situation?*
How long have you been in your current living situation?*
INCLUDING YOURSELF, how many adults are in your household? (18 and older)*
How many children are in your household? (under 17)*

Are you employed?*
Do you receive any income such as wages from a job, Social Security, Unemployment, Child Support, etc?*
Does your household receive any non-cash benefits such as Food Stamps, WIC or TANF?*
Current household monthly income (total monthly household income)*
How much is your monthly housing cost? (rent, mortgage, or fee)*

Do you have medical insurance?*
What type of medical insurance do you have?*
Do you have a primary care doctor?*
Who is your primary care doctor?*
Do you have any disabling conditions?*
Select yes if you have a physical, mental, emotional or developmental disability, HIV/AIDS, or a diagnosable substance abuse problem that is expected to be of long duration and substantially limits your ability to live on his or her own.
Disabling Condition(s)*
Are you struggling with your mental health?*
To Speak to counselor immediately: Text: CARE4U to 741741 Call: 1-800-273-8255
Do you have dependency issues with alcohol or drugs?*

Purpose of this form: St. Johns Care Connect, Inc. (“the Agency”) is a participating provider of vital services (“Participant”) who is an active project of the Care Connect Information Network (CCIN) hosted by St. Johns Care Connect, Inc. CCIN participating agencies work together to provide services to persons and families in need. When you request or receive services, we may collect data about you and your household such as:
1. Your name, date of birth, Social Security Number, gender, ethnicity, race, veteran status, prior residence and program status.
2. Your service needs, income, benefits, education, employment, destination, disability, general health, as well as pregnancy, HIV/AIDS, behavioral health, legal, and domestic violence status, destination.
3. How will my data be used? The ways in which the Agency may use or disclose your information are discussed in our Notice of Privacy Practices, which is posted here: Privacy Policy.
4. How will my data be protected? We enter your data in a computer program that is protected by passwords and encryption technology. Each Participant and CCIN user must sign an agreement to maintain the security and confidentiality of the information. Any person or Participant that violates the agreement may lose their access rights and be subject to further penalties.
5. How do I benefit by providing the requested information and sharing it with other agencies? By sharing your information with other agencies, you may be able to avoid being screened again, get services faster, and minimize how many times you have to tell your “story.” You also help agencies document the need for services and demonstrate that funding is needed.
Client Informed Consent/Authorization for Release of Information - By signing this form, I agree that the Agency may disclose and other participating agencies in the SERVICEPOINT may use the following information for lawful purposes of the agencies that participate in the SERVICEPOINT and their employees and agents:*
List the individuals affected by this Release of Information (ROI). If this is a household situation, please include household members affected by this ROI.*
Signature of the Individual or Guardian (typed name)*

I agree that this agreement may be electronically signed. I agree that the electronic signature appearing on this agreement is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility. I understand that •I am not required to sign this consent and that if I refuse to sign this consent my treatment, payment, or eligibility for benefits will not be affected. I may also request a copy of this consent after I sign it. •This consent form expires in seven (7) years. I have the right to revoke this consent at any time by writing to the Agency, except to the extent that the agency has acted in reliance on it. Past information I previously consented to release will not be retrieved from agencies that received that information. I understand that my revocation must be in writing. •The Agency has posted a Notice of Privacy Practices, and I may request a paper copy of the Notice from the Agency. I acknowledge that I have been given an opportunity to read and/or request a copy of the Notice and that I have read the Notice. The Notice describes ways in which my personal information may be used and disclosed within and outside of the Agency. Its terms may change and I may obtain a copy of the Notice by writing to: CCIN SERVICEPOINT c/o Flagler Health+ Care Connect, 400 Health park, Blvd. St. Augustine, FL 32086. •I understand that neither the Agency, nor the CCIN, can control how another Participant will use or disclose my information that it receives under this consent. It is possible that the other agency will disclose my information to others, and that the disclosed information may no longer be protected by federal privacy regulations.
By submitting this form, I agree to share all of my information with Care Connect and other participating agencies in the Care Connect Information Network. Care Connect will only disclose my information to agencies on a need to know basis. Care Connect will advocate on my behalf based on the services being requested and information I provide. If I request services from another partnering agency, the information I have shared with Care Connect will be viewable to the partnering agency avoiding duplicative screening.

Get Connected

Please complete the following form. Once you submit the form, a Community Health Associate from our team will contact you to complete an intake and discuss your form. We look forward to connecting with you!

Step 1 of 6 - Contact Information

Get Connected

Please complete the following form. Once you submit the form, a Community Health Associate from our team will contact you to complete an intake and discuss your form. We look forward to connecting with you!

Step 1 of 6 - Contact Information

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