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Get Connected to the Benefits You May Qualify For

California Benefits Support Center (CBS) provides FREE, personalized assistance to help you apply for California benefits, including CalFresh and Medi-Cal, and connect with essential community resources.

Take the first step toward better health, greater stability, and a brighter future—all at no cost to you.

Complete the CBS Benefits Registration Form below to get started!

CBS Benefits Registration Form

Need help completing this form? Just complete sections 1 and 2, then submit, and a CBS team member will contact you within 2 business days.

Do not include Social Security Numbers on this form.

  1. Program/Application Type
Select all that apply
  1. Participant Information
Date of Birth
Buwan
Araw
Taon
Multi-line address
Gender
Currently experiencing homelessness?
Preferred language
Us citizen?
Yes
No
Are you a veteran
Do you receive veteran benefits?
  1. Household, Income & Demographics
Gender (optional)?
Male
Female
Trans MTF
Trans FTM
Non-binary
Other
Race (optional)?
White
Latinx
Black
Asian American/Pacific Islander
Native American
Other
  1. Medical Coverage & Costs
Two or more ER visits/inpatient stays in the past 12 months?
Yes
No
  1. Qualifying Medical Condition Information
  1. Prescription Details (if applicable)
  1. Referrer Information
Referred by?
Self
Other
  1. What Do You Need Help With?
Select all that apply:
  1. How Did You Hear About Us?
Select all that apply:
  1. Additional Information
  1. Preferred Contact Method
How should CBS contact you?
Phone
Email
  1. Consent to Contact
I agree CBS may contact me about my request, application, or services
I agree
I agree CBS may contact the referrer(s) listed on this form
I agree

To complete this form, click the Submit botton below and we will be in touch with you within 2 business days.

Note: Submitting this form does not guarantee eligibility for benefits or services.

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