Submit a request – The Connection Initiative

Your email address

Subject

What type of resource or connection do you need today?

What type of home and housing connection do you need? Examples include finding immediate shelter, repairing your home, and requesting mortgage or rent support.(optional)

What type of health connection do you need? Examples include connecting with a doctor or hospital, locating treatment resources and medical equipment, and support for substance use. If this is an emergency, please contact 911.(optional)

What type of food connection do you need? Examples include connecting with food banks, accessing food delivery, and nutrition education. (optional)

What type of education and employment connection do you need? Examples include adult education and professional development support and K-12 education or socioemotional learning support. (optional)

What type of transportation connection do you need? Examples include coordinating a ride to an event or an appointment and requesting vehicle maintenance support.(optional)

What type of safety connection do you need? Examples include support for suvivors of domestic abuse and locating resources for neighborhood safety. If this is an emergency, please contact 911. (optional)

What type of community connection do you need? Examples include interest in volunteering, need for volunteers, and information for community events.(optional)

What resource or connection do you need today?(optional)

Who are you making this request for?(optional)

Is the client or community member aged 55 years or older and currently residing in Washington County, Maine?(optional)

If these factors apply, the client or community member may be eligible for additional resources.

What is your relationship to the person you are making this request for?(optional)

With what organization are you affiliated?(optional)

Confirmation of Information Sharing(optional)

The privacy of our neighbors is important to us. TCI expects that you have received consent to share this information. Please confirm that you have attended to all necessary steps to make this request.

Your First Name(optional)

Your Last Name(optional)

Your Town

What town or municipality do you live in?

Other Town

What town or municipality do you live in?

Your Pronouns(optional)

What pronouns do you use?

Your Email Address(optional)

Your Phone Number(optional)

Your Preferred Contact Method

This allows TCI to effectively reach out to you. If you select "Text Message" as your Preferred Contact Method you agree to receive support messages from The Connection Initiative. Data/SMS rates may apply. To opt-out of messages, reply STOP at anytime.

Community Member or Client First Name(optional)

Community Member or Client Last Name(optional)

Community Member or Client Town

What town or municipality does the person live in?

Other Town

What town or municipality does the person live in?

Community Member or Client Pronouns(optional)

What pronouns does the person use?

Community Member or Client Email Address(optional)

Community Member or Client Phone Number(optional)

Community Member or Client Preferred Contact Method

This allows us to reach you.

Age Range(optional)

What is the age range of the person looking for a resource?

Are you or the person looking for a resource a veteran?(optional)

Description

Please provide a brief description of your need.

Urgency of Resource(optional)

In what timeframe do you need this connection?

What is the ideal outcome to your situation?(optional)

Referred By(optional)

How did you learn about The Connection Initiative?

Fuel or Supply Type(optional)

What type of fuel do you use?

Number of Household Members(optional)

Ages of People in Household(optional)

Please list the ages of the people in your household.

Utility Provider(optional)

Financial Need Amount(optional)

How much financial support do you need?

Dietary Requirements or Preferences(optional)

Please tell us about any relevant dietary requirements.

What organizations have you reached out to or worked with related to this need?(optional)

This will help us make a more efficient connection.

Consent to Information Sharing(optional)

Your privacy is important to us. Please check this box if you consent to us sharing your information with our Resource Partners.

Should Not See Requester Info(optional)

Please list any individual or organization with whom you would prefer we not share details of your request.

Terms of Use Agreement

By making this request, you are agreeing to the terms of use and privacy policies of The Connection Initiative. Review these policies here: https://www.connectioninitiative.org/privacy

D-PHI: Downeast Population Health Initiative(optional)

The Connection Initiative is working to connect adults who are 55 and older to resources and trusted community support to improve health and well-being. Please check this box if you consent to Resources Partners collaborating on the TCI platform to address your resource need. This program may include an opportunity to provide additional feedback about your experience. For more information about the Downeast Population Health Initiative project evaluation, visit: https://connectioninitiative.org/d-phi

Distress Level(optional)

What number (0-10) best describes how much distress you have been experiencing in the last week?

Social Isolation(optional)

How often do you feel lonely or isolated from those around you?

Community Support and Connection(optional)

Rate the following statement from Strongly Disagree (1) to Strongly Agree (5): “I have people in my community who I can trust when I need help.”

Highest Priority Challenge(optional)

Which of the following (if any) would you say is your biggest challenge right now?

Other Highest Priority Challenge(optional)

What is your highest priority challenge right now?

Primary Care Challenges(optional)

Accessing or navigating primary care, scheduling appointments, or feeling heard and understood by healthcare providers. “Let’s talk about your experiences with primary care. Many older adults in this area face challenges like long waits or feeling like their provider doesn’t fully understand their needs. Let me know if any of these feel relevant to you.”

Primary Care Challenges(optional)

Select challenges related to primary care (select all that apply, yes/no):

Other Primary Care Challenges?(optional)

Are you experiencing any other primary care challenges? Check to select yes.

Other Primary Care Challenges(optional)

What other primary care challenges are you experiencing?

Cancer Care Challenges(optional)

Addressing barriers to cancer treatment, emotional support, or navigating survivorship needs. “Cancer care can be overwhelming. I’m going to ask a few questions to understand how your diagnosis, treatment, or follow-up care may be affecting you. Let me know which of these apply to you so we can prioritize where you need support.”

Cancer Care Challenges(optional)

Select challenges related to cancer care (select all that apply, yes/no):

Other Cancer Care Challenges?(optional)

Are you experiencing any other cancer care challenges? Check to select yes.

Other Cancer Care Challenges(optional)

What other challenges related to cancer care are you experiencing?

Independence and Safety Challenges?(optional)

Concerns about memory, mobility, or creating a safe home environment. “Let’s explore how you’re managing your independence and safety. Some people worry about memory, mobility, or even their home setup. Let me know if any of these challenges apply to you so we can address them together.”

Independence and Safety Challenges(optional)

Concerns about memory, mobility, or creating a safe home environment.

Other Independence and Safety Challenges?(optional)

Are you experiencing any other independence and safety challenges? Check to select yes.

Other Independence and Safety Challenges(optional)

What other challenges related to independence and safety are you experiencing?

Financial and Resource Challenges?(optional)

Difficulty affording healthcare, transportation, or accessing essential resources like food or medical supplies. “Financial challenges often make it hard to focus on other areas of life. I’ll ask a few yes-or-no questions to understand where costs or resources might be barriers for you.”

Financial and Resource Challenges(optional)

Difficulty affording healthcare, transportation, or accessing essential resources like food or medical supplies.

Other Financial and Resource Challenges?(optional)

Are you experiencing any other financial and resource challenges? Check to select yes.

Other Financial and Resource Challenges(optional)

What other challenges related to finances and resources are you experiencing?

Caregiving and Personal Support Challenges?(optional)

Struggles with caregiving responsibilities or accessing help for personal care or daily tasks. “Caregiving or needing help yourself can be exhausting. I’m going to ask some questions about how you’re managing, and you can let me know if any of these apply to your situation.”

Caregiving and Personal Support Challenges(optional)

Struggles with caregiving responsibilities or accessing help for personal care or daily tasks.

Other Caregiving and Personal Support Challenges?(optional)

Are you experiencing any other caregiving and personal support challenges? Check to select yes.

Other Caregiving and Personal Support Challenges(optional)

What other challenges related to caregiving and personal support are you experiencing?

Community Connection and Social Support Challenges?(optional)

Feeling isolated, disconnected, or lacking access to meaningful relationships or community activities. “Feeling connected to a community is important for well-being. I’ll ask some yes-or-no questions about how you feel in your community and what might make those connections stronger.”

Community Connection and Social Support Challenges(optional)

Feeling isolated, disconnected, or lacking access to meaningful relationships or community activities.

Other Community Connection and Social Support Challenges?(optional)

Are you experiencing any other community connection and social support challenges? Check to indicate yes.

Other Community Connection and Social Support Challenges(optional)

What other challenges related to community connections and social support are you experiencing?

Attachments(optional)

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