Digital Navigator Intake

"*" indicates required fields

Digital Navigator

Enter Navigator Name

Organization Name*

Client Name

Client Age*

Gender Identity*

Client Race*

Is the client living in a rural area?*

Zip Code*

ZIP Code

Is the client living with disabilities?*

Does the client have a low English proficiency?*

Is the client deaf or hard of hearing?*

Is the client in a correctional setting?*

Is the client a veteran?*

Is the client an immigrant, refugee, or an asylum seeker?*

Does the client qualify for SNAP or Federal Public Housing Assistance? If so, they might also qualify for offers related to digital services.*

Would the client like assistance with Affordable Connectivity Program or Internet Access*

Name

First Last

Phone

Is the client receiving Medicare?*

County*

This field is for validation purposes and should be left unchanged.