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

common.other_option

How many people live in your household?

1

2

3

4

5

6+

Your Medicaid CIN Number (Example: YX12345Z) *

Please provide the names, dates of birth, and CIN numbers (e.g., YX12345Z) of other family members.

Have you previously been screened for the SCN Program?

Yes

No

Not Sure

Are you interested in learning whether you qualify for Food & Nutrition Support services through the SCN Program?

Yes

No

What is your Full Name? *

What is your best phone number? *

What is your best email address? *

Address

Street Address

City

State

Country

Enter your country

Postal Code

Date of birth

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