Assistance Request Form

If you are experiencing an urgent need or the form fields are not populating below, please dial 2-1-1 or 888-892-1162 (available 24 hours a day 7 days a week) to contact NC 211 by United Way of North Carolina for assistance. *Please note that some mobile devices that have an unstable or weak WiFi connection may not be able to populate the form fields below. If this happens, please try to connect to a stronger WiFi network OR please dial 2-1-1 or 888-892-1162 to get connected.

If you are experiencing an urgent need unrelated to COVID-19 and you would like to be connected to services near you, please complete the form below and an NCCARE360 Resource Navigator from NC 211 will contact you. The information you enter is completely confidential and will only be shared in order to connect you to services.

If you are a veteran or military-connected family member, click here to get help.

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.