Coordinated Intake Form

Coordinated Intake Form

Consent to Share Information

Welcome to the Ready to Learn coordinated intake process! By completing this form, you are providing consent for Ready to Learn Navigators to provide you with referrals for services.

To participate in this process, we will need to gather some information from you. The information is collected via online form. Once you provide information, a Navigator will follow up with you to get any additional information needed and to provide referrals. If you prefer to use a phone-based referral service, please dial 2-1-1. Information needed for this form is outlined below.

What information is required?

Required items include your name, phone number, date of birth, zip code, services needed, number of children in the household, and how you heard about the form. All other items are optional. Please note that you only have to share as much as you are comfortable sharing, although service providers may request additional information later to determine eligibility for services.

Who will be able to see the information?

Your information will be visible to Navigators from Alignment Rockford and Rosecrance. Illinois Action for Children, who is funding the intake, will also be able to see your information. Portions of the information provided may be shared with service providers for the purpose of referring your family to the services you requested and with evaluators for the purpose of measuring the effectiveness of the work. When information is shared beyond these groups, it will always be de-personalized (i.e. not containing any information that could linked back to you) and aggregated (i.e. combined with others' information).

Consent

By signing below, I am indicating that I have read and understand the above. I am providing permission for my information to be shared in the capacity outlined above.

Name*

Today's Date*

About You

Date of Birth*

Zip Code*

Phone Number*

Email Address

Primary Language Spoken at Home

Select or enter value

Other Language: Please Specify

What is the best way to reach you?

Select

When is the best time to reach you?

Select

About Your Household Needs

Your privacy is important to us. The information collected in the next question is about the needs of your household. This information will be shared with a community resource navigator who will connect you with agencies that provide services responsive to your needs.*

I consent.

Do you have a safe phone number or email where we can contact you regarding domestic violence resources?*

Select

Please enter the safe phone number or email:

No safe contact available*

For your safety, we will not contact you about domestic violence services. Instead, we encourage you to visit this page for a list of resources. Please check the box below to indicate you understand.

Number of Children in Your Household Ages 21 and Under*

Select

First Name of Child #1

Date of Birth of Child #1

Services Needed for Child #1

First Name of Child #2

Date of Birth of Child #2

Services Needed for Child #2

First Name of Child #3

Date of Birth of Child #3

Services Needed for Child #3

First Name of Child #4

Date of Birth of Child #4

Services Needed for Child #4

First Name of Child #5

Date of Birth of Child #5

Services Needed for Child #5

First Name of Child #6

Date of Birth of Child #6

Services Needed for Child #6

First Name of Child #7

Date of Birth of Child #7

Services Needed for Child #7

First Name of Child #8

Date of Birth of Child #8

Services Needed for Child #8

First Name of Child #9

Date of Birth of Child #9

Services Needed for Child #9

First Name of Child #10

Date of Birth of Child #10

Services Needed for Child #10

Please provide any additional information on services needed

Services you or others in your household are current receiving. Please select all that apply.

Select or enter value

Please share what other services you or others in your household receive.

How did you hear about this coordinated intake?*

Select or enter value

Which service provider or organization?

Which type of Social Media?

Which Newsletter?

Which website?

Please specify

Other Programs/Services

For parents of children ages 0-5, are you aware of the following parenting supports in your community?

Select

Have you downloaded the Beginning with Babble app?

Select or enter value

Have you used the Basics with your family?

Select

Have you received a Basics learning kit?

Select or enter value

Would you like to receive a Basics learning kit?

Select or enter value

Are you currently (or were you previously) enrolled in Opening Doors/Abriendo Puertas?

Select

Are you currently (or were you previously) enrolled in the Incredible Years?

Select or enter value

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