What Programs are Right for Me?
Please fill in the form below
Who are you completing this form for?
*
Self
Other Adult
Child Under the Age of 18
Do you live in any of the below counties?
Apache
Coconino
Gila
Mohave
Navajo
Yavapai
Does the person(s) you are completing this for live in any of the below counties?
Apache
Coconino
Gila
Mohave
Navajo
Yavapai
Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
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1921
1920
Year
Assigned Sex at Birth
Male
Female
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Personal Information
Are you a US Citizen? *
Yes
No
Is the person(s) you are completing this for a US Citizen(s)?
Yes
No
Are you a Native American or an Alaskan Native?
Yes
No
Is the person(s) you are completing this for Native American or Alaskan Native?
Yes
No
Are you a Veteran?
Yes
No
Is the person(s) you are completing this for a Veteran?
Yes
No
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About the Applicant
Monthly household income (pre-tax USD)
*Monthly income ONLY
Number of family members in the household?
Only me
2
3
4
5
6
7
8
9
10
11
12+
Calculation
Do you have health coverage? (Medicare, AHCCCS, or Private Insurance)
Yes
No
I don't know
Does the person(s) you are completing this for have health coverage? (Medicare, AHCCCS or Private Insurance)
Yes
No
I don't know
Does your insurance cover dental services?
Yes
No
I don't know
Does their insurance cover dental services?
Yes
No
I don't know
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Health-Related Information
Are you pregnant or nursing or is anyone in the house under 5 years old?
Yes
No
Is the person(s) you are completing this for or anyone in the house pregnant or nursing or is anyone in the house under 5 years old?
Yes
No
Do you have a chronic condition?
Yes
No
Does the person(s) you are completing this for or anyone in the house have a chronic condition?
Yes
No
Are you suffering from symptoms of depression or anxiety?
Yes
No
Does the person(s) you are completing this for or anyone in the house suffering from symptoms of depression or anxiety?
Yes
No
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Situational Information
Are you a victim of sexual assault or domestic violence?
Yes
No
Is the person(s) you are completing this for or anyone in the house a victim of sexual assault or domestic violence?
Yes
No
Do you have issues with substance abuse?
Yes
No
Does the person(s) you are completing this for or anyone in the house have issues with substance abuse?
Yes
No
Are you experiencing homelessness?
Yes
No
Is the person(s) you are completing this for or anyone in the house experiencing homelessness?
Yes
No
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