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ESPANOL
ESPANOL
Tell us a little about yourself so we can match you to the programs you are eligible for.
Do you live in Sacramento County?
*
Yes
No
Age
ZIP Code
*
94571
95608
95610
95615
95621
95624
95626
95628
95630
95632
95638
95639
95641
95652
95652
95655
95660
95662
95670
95673
95680
95683
95690
95693
95742
95757
95758
95811
95814
95815
95816
95817
95818
95819
95820
95821
95822
95823
95824
95825
95826
95827
95828
95829
95830
95831
95832
95833
95834
95835
95837
95838
95841
95842
95843
95864
Race / Ethnicity
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Hispanic/Latino
Multiple Races
Other
Language Preference
English
Spanish
Other
Gender
Female
Male
Other or Not Disclosed
Number of people living in your household
1
2
3
4
5
6
7
8
9+
Are you or your partner pregnant?
Yes
Due Date
MM slash DD slash YYYY
Are You Experiencing a High Risk Pregnancy?
Yes
Is this your first child?
Yes
Monthly Household Income Before Taxes
$0 - $1,215
$1,216 - $1,643
$1,644 - $2,072
$2,073 - $2,500
$2,501 - $2,928
$2,929 - $3,357
$3,358 - $3,785
$3,786 - $,4,213
$4,214+
Do you need help with any of the following?
Getting medical or dental insurance
Finding a doctor or a dentist
Breastfeeding
Basic Needs (i.e food, housing)
Support with mental health or counseling (for yourself)
Support with mental health or counseling (for your child)
Parenting Support or Workshops
Crisis Support
Check all that apply.
Complete if you are a parent or caretaker of a child aged 0-17 years old
Dependents
Age of Child (0 if under 1 y/o)
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