Intake Form

Exit Survey

Hello: In order to receive services, we need you to complete this intake form for our records. It may take 30 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.

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.) Program Assistant: Alberta Wilson; Case Manager: Mamie Asenbauer

NCIDC's Crescent City (Del Norte) office number is (707) 464-3512. Regional Manager/Case Manager: Jeremiah Swain

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

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

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