Assistance Request Form

If you would like to be connected to services near you, please complete the form below and a NCCARE360 Navigator from NC 2-1-1 will contact you. The information you enter is completely confidential and will only be shared in order to connect you to services.

Please use this form only to request services for yourself, or a child (under 18 years old) or adult for whom you have legal guardianship. Consent submitted through this form should be signed by the person who would be receiving services, or signed by their parent or legal guardian only.