Date of Birth(Required)

Screening Questions

This screening tool is being offered to help connect you to services in your community that may improve your health. Please answer the following questions to help us better understand your current situation. By answering these questions, we may be able to provide you with connections to services or programs that may help you. The information that you provide will not affect your insurance. There are no right or wrong answers, and the screening will not impact clinical care.
Do you worry about losing your current home or current living situation and need stable housing?
Do you worry about the current conditions where you live (e.g., pests, lead exposure, and working appliances)?
At times, do you run out of food and/or not have enough money to get more?
Does lack of transportation keep you from medical appointments, picking up medications, work, or from doing things needed for daily living?
Has the electric, gas, or water company shut off services or currently threatening to shut off services in your home?
Do you worry about your personal safety? Are you worried about being physically harmed, insulted, talked down to, threatened, and/or screamed or cursed at?
Do you currently need education resources (e.g., GED, ESL classes, etc.)?
Do you currently need help searching for or maintaining a job?
Do you need financial assistance to help pay for childcare, healthcare, etc.?
Do you currently need affordable household goods and supplies (e.g., clothing, diapers, furniture, etc.)?
At this time, which of the following would you like staff to help you find resources? Select ALL that apply.
Check this box if you would like to decline screening at this time.