Home ScreenWell West Michigan ScreenWell West Michigan Request Assistance The ScreenWell West Michigan fund supports individuals, families, and small businesses who need help covering the cost of screening services. Please complete the form below. Our teams review all requests, and offer support on a rolling basis as funds become available. Contact Information Assistance Type IndividualFamilySmall Business / Organization Residency & Household Information Household Size Including yourself, how many individuals live in your household? 1 (Just me)2345678910+ Annual Household Income Please select the range that best represents your total household income before taxes. Under $15,000$15,000 – $24,999$25,000 – $34,999$35,000 – $49,999$50,000 – $74,999$75,000 or above Employment Status Employed full-timeEmployed part-timeSelf-employedUnemployed – seeking workUnable to workRetiredStudent Are you currently receiving any of the following? (Select all that apply) SNAP / Food AssistanceMedicaid / MIChildWICHousing Assistance / Section 8SSI / SSDIMichigan Works / UnemploymentNone of the above Is this request related to a court order or legal requirement? YesNoNot Sure Type of Screening Assistance Requested Drug & Alcohol TestingDNA TestingFingerprinting ServicesBackground ChecksCourt-Ordered or Legal TestingEmployment / Pre-Employment TestingWellness or Compliance ScreeningOther Requested Date of Service Have you received assistance through this fund before? YesNoNot Sure Additional Information Is there anything else you'd like us to know about your situation or need? Preferred Method of Contact TextPhone CallEmail Certification & Consent By submitting this form, I certify the information provided is accurate and authorize Compass to review my request. I agree
