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Intro: Thank you for completing this form. Please tell us a little about your situation so we can connect you to the right support. The information you provide in this form will not be shared with anyone without your permission. This takes about 2–3 minutes.
1. Who are you completing this for? (Select one)
2. What is your housing situation today? (Select one)
3. Within the past 12 months, you worried that your food would run out before you got money to buy more. (Select one)
4. In the past 12 months, has a lack of transportation kept you from medical appointments, meetings, work, or getting things needed for daily living? (Select one)
5. In the past 12 months, has an electric, gas, or water company threatened to shut off services in your home? (Select one)
6. Currently, are you experiencing any physical or mental abuse or financial exploitation? How often does anyone, including family, physically hurt you or threaten you? (Select one)
7. Do you have any chronic health conditions such as diabetes, high blood pressure, or congestive heart failure? (Select one)
8. Over the past two weeks, have you felt down, sad, depressed, or bothered? If so, how often? (Select one)
9. What type of insurance coverage do you have? (Select one)
10. Preferred Contact Information
11. Consent to Be Contacted

Submitting this form does not guarantee eligibility for any program. A team member will follow up to review your information and discuss available support options.