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Digital Navigator Intake
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*
" indicates required fields
Digital Navigator
Enter Navigator Name
Organization Name
*
Select organization
Not Listed
AHANA-MEBA
Asia Pacific Cultural Center
CACCWA
Comunidades Sin Fronteras WA
ESES Collective
Filipino Community of Seattle
Khmer Community of Seattle - King County
Latinos En Spokane
Latinos Unidos
MindSight Mentors
Mission Africa
Mother Africa
Organization Centro-Americano
Pierce for Healing
T3 -Tribal Technology Training
THAC
Client Name
Client Age
*
Select Age Range
0-6
7-10
11-17
18-24
25-59
60+
Gender Identity
*
Select Gender
Female
Male
Non-Binary
Genderqueer
Prefer not to disclose
Client Race
*
Select Race
Alaskan Native/American Indian
Asian
SE Asian
Black or African American
Hispanic, Latinx, or Spanish
Multiracial
White
Prefer not to disclose
Is the client living in a rural area?
*
Is client living in Rural area
Yes
No
Prefer not to disclose
Zip Code
*
ZIP Code
Is the client living with disabilities?
*
Please select one of the options
Yes
No
Does the client have a low English proficiency?
*
Please select one of the options
Yes
No
Is the client deaf or hard of hearing?
*
Please select one of the options
Yes
No
Is the client in a correctional setting?
*
Please select one of the options
Yes
No
Is the client a veteran?
*
Please select one of the options
Yes
No
Is the client an immigrant, refugee, or an asylum seeker?
*
Please select one of the options
Yes
No
Prefer not to disclose
Does the client qualify for SNAP or Federal Public Housing Assistance? If so, they might also qualify for offers related to digital services.
*
Please select one of the options
Yes
No
Prefer not to disclose
Would the client like assistance with Affordable Connectivity Program or Internet Access
*
Please select one of the options
Yes
No
Prefer not to disclose
Name
First
Last
Phone
Email
Is the client receiving Medicare?
*
Please select one of the options
Yes
No
Prefer not to disclose
County
*
Select County
Adams County
Asotin County
Benton County
Chelan County
Clallam County
Clark County
Columbia County
Cowlitz County
Douglas County
Ferry County
Franklin County
Garfield County
Grant County
Grays Harbor County
Island County
Jefferson County
King County
Kitsap County
Kittitas County
Klickitat County
Lewis County
Lincoln County
Mason County
Okanogan County
Pacific County
Pend Oreille County
Pierce County
San Juan County
Skagit County
Skamania County
Snohomish County
Spokane County
Stevens County
Thurston County
Wahkiakum County
Walla Walla County
Whatcom County
Whitman County
Yakima County
Phone
This field is for validation purposes and should be left unchanged.