Navigation Support Intake Form

ICS Foundation provides non-clinical navigation support to help individuals, families, and organizations understand and access public benefits and community resources.
This intake helps us understand your situation and determine whether we can offer next steps. Submission does not guarantee services.

Who is this request for?

Individual / Family
Organization / Institution
Advisor / Partner
Faith-Based or Community Group
Other
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Company Name *

What do you need help with?

Navigating or coordinating services
Building or improving a community, residential, or place-based program
Fixing or improving internal systems
Training or technical help
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Are any larger systems involved?

Public benefits (e.g., Medicaid / waivers)
Housing or supportive services
Health or behavioral health
Education or workforce
Justice or reentry
None / not sure
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Where is support needed?

Washington, DC
Maryland
Other
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Which fits best right now?

I am seeking paid services
I am seeking sponsorship-supported help
Not sure
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Do you currently receive SSI or SSDI benefits?

Yes
No
In progress / applied
Not sure
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Do you currently have Medicaid coverage?

Yes
No
In progress / applied
Not sure
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Funding Type

Select option

Self-pay
Organization-paid
Foundation review
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What are you trying to navigate right now?

Health coverage or Medicaid

Long-term services or disability supports

Housing or housing-related services

Reentry or returning citizen supports

School, youth, or family-related services

Multiple systems at once

Not sure / need help figuring it out

Is there a time concern we should be aware of?

Yes — something is urgent

There is a deadline, but it’s not urgent

No immediate timeline

Not sure

In your own words, briefly describe what’s going on (What’s making this hard to navigate right now?)

If there is a deadline or urgent issue, briefly note it here (optional)

First Name

Last Name

Phone *

Email *

Were you referred by a partner?

Yes

No

If Yes, please provide referral agent name or code.

I understand this is non-clinical navigation support and that submitting this form does not guarantee services. *

Yes

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

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