Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

CARES Project Screener

  1. CARES T.E.A.M. Services Request

  2. please enter the mm/dd/yyyy for your date of birth.

  3. Are you currently a Norfolk resident? *

  4. Are you currently receiving SNAP or Medicaid benefits?*

  5. Are you currently receiving TANF benefits?*

  6. Was your employment impacted by the COVID-19 pandemic?*

  7. If you answered Yes, to the above question, please check one of the below on how you were impacted by COVID-19*

    Enter N/A if you answered No to being impacted by the COVID-19 pandemic.

  8. Please check what type of assistance you are interested in receiving. *

  9. Have you ever been convicted of a misdemeanor or felony charge*

  10. Leave This Blank:

  11. This field is not part of the form submission.