United Family Support Services

United Family Support Service

Where do you live? *

Brooklyn

The Bronx

Queens

Manhattan

Staten Island

Dutchess County

Orange County

Rockland County

Sullivan County

Ulster County

Westchester County

Other (we may not currently serve your area)

Are you currently enrolled in Medicaid?

Yes

No

Not Sure

Are you currently receiving Food & Nutrition services through the SCN Program?

Yes

No

Not Sure

Do you or anyone in your household have any of these conditions or situations?

Chronic condition, such as diabetes, CHF, COPD, cancer

Mental illness

Substance use disorder

Pregnant or postpartum

High-risk child

What insurance does your child have?

What is your child’s date of birth?

(Optional — but helps verify eligibility)

What is your Zip code? (this helps us know that we are reaching people in our area) *

What is your Full Name? *

What is your best phone number? *

What is your best email address? *

I agree to the terms & conditions provided by Unite Family Support Services, and by providing my phone number, I agree to receive text messages from Unite Family Support Services.