Name(Required) First Last Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920EmailScreening QuestionsThis 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? Yes No Do you worry about the current conditions where you live (e.g., pests, lead exposure, and working appliances)? Yes No At times, do you run out of food and/or not have enough money to get more? Yes No Does lack of transportation keep you from medical appointments, picking up medications, work, or from doing things needed for daily living? Yes No Has the electric, gas, or water company shut off services or currently threatening to shut off services in your home? Yes No 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? Yes No Do you currently need education resources (e.g., GED, ESL classes, etc.)? Yes No Do you currently need help searching for or maintaining a job? Yes No Do you need financial assistance to help pay for childcare, healthcare, etc.? Yes No Do you currently need affordable household goods and supplies (e.g., clothing, diapers, furniture, etc.)? Yes No At this time, which of the following would you like staff to help you find resources? Select ALL that apply. Stable housing Transportation Education resources Financial assistance Living conditions (e.g., pests, lead exposure) Utilities (e.g., heat, electricity, water) Affordable household goods and supplies Food Personal safety Job At this time, I do not want help Check this box if you would like to decline screening at this time. Decline screening
