Get Started - Smart Start Modoc County

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Tell us about yourself
A service provider assisted me to enter this information with my permission.*
- Yes
- No
Service Provider Name*
Service Provider Phone Number*
Service Provider Email*
Are you receiving out of county services?
Counties
I am a resident of Modoc County*
Counties
Name
First Name Last Name
Date of Birth
Month
Day
Year
Phone
Email
ZIP Code*
Race / Ethnicity
Language Preference
Gender
Disability Status
- I am disabled
Number of People Living in Household
Are you or your partner pregnant?
- Yes
Due Date
MM slash DD slash YYYY
Are You Experiencing a High Risk Pregnancy?
- Yes
Do you need to travel outside Modoc County for medical appts related to pregnancy?
- Yes
Employment Status
Monthly Household Income Before Taxes
*Best Guess
Housing Status
Check all that apply
- Are You Enrolled in Medical (Partnership Health Plan)?
- Do you Receive TANF or CalWorks?
- Do you Receive Calfresh/Food Stamps?
- Do you want information about quitting tobacco/nicotine?
- Are you concerned about health effects of second hand smoke, third hand smoke or vaping?
- Do you receive WIC?

Dependents - Including Babies in Utero
Dependents
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802 N. East Street – Alturas, CA 96101 Phone 530-233-7122

Tell us about yourself