JumpStartSCN

JumpStart SCN

Client Referral & Screening

Connect New Yorkers with food, housing, and transportation support.

Section 1 · Client Demographics

Format: 2 letters, 5 numbers, 1 letter (e.g. AB12345C).

Section 2 · Household Members

Is anyone in the household pregnant or postpartum? *

Section 3 · Screening Questions

1. Does your household need help with food? *

2. Does your household receive WIC or Food Stamps (SNAP)? *

3. Does anyone in the household currently work? *

4. Does anyone in the household have dietary restrictions or food allergies? *

5. Does anyone in the household need help with transportation? *

6. Is your household behind on paying rent? *

7. Does your household receive Section 8 housing assistance? *

8. Has your household's electricity been shut off or received a shut-off notice? *

Client Status *

Select New Client if this is the first time enrolling in the SCN program, or Transfer Client if they are moving from another SCN provider.

Provider Attestation (optional)

If you have a signed provider attestation, you may upload it here. This is optional. Accepted: PDF or image files, up to 10MB.