Intake Form

Exit Survey

Hello: In order to receive services, we need you to complete this intake form for our records. You will need to have information about you and your household's income as well as documentation (such as a paycheck stub, last years tax return, benefit statement, etc. in addition to your ID) on hand and it may take 10-15 minutes to complete.

Please make sure to read each question carefully.

Your responses will be strictly confidential and this website is highly secure. If you have questions at any time about the form or the process, contact your local office/organization.

We would also like to inform all single-parent applicants that California offers assistance for obtaining and/or managing child support from the other parent of your child. More information can be found at https://childsupport.ca.gov/apply-for-child-support/.

NCIDC and Walking Shield Office Numbers
Northern California Indian Development Council's (NCIDC) Eureka office number is (707) 445-8451 or you can call us toll free at (800) 566-2381. (This office also offers services statewide if you do not see your county below.) Case Manager: Alisha Johnson

NCIDC's Crescent City (Del Norte) office number is (707) 464-3512. Case Manager: Brenda Lawrence

NCIDC's Yreka (Siskiyou) office number is (530) 842-6157. (This office also serves Butte and Shasta County.) Regional Manager/Case Manager: Joyce Jones; Intake Specialist: Rosie Kerr

Walking Shield's Costa Mesa office number is (657) 900-2197. This office serves Orange County.

Please start the survey now by clicking on the Next button below.