What is impacting your overall health? Complete the form below and indicate if you’d like our assistance. Individual Name First Last Individual Date of Birth Is individual 18 years of age or older?(Required) Yes No Contact Information(Email and/or Phone Number) Which programs are this individual enrolled in? (Select all that apply; if none leave this section blank) Applied Behavioral Analysis (ABA) Therapy Clinic Services (Physical/Occupational/Speech/Sensory Therapy) Berkana Crisis Respite Bridge Services Children’s Services Community Habilitation Community Oriented Recovery & Empowerment (CORE) Services Community Support Services (CSS) Consumer Directed Personal Assistance (CDPA) Court Appointed Special Advocates (CASA) David Clark Learning Center Day Habilitation DD/ABI Housing Services Employment Services Family Support Services Family Support & Education Center Mental Health Home and Community Based Services (HCBS) Mental Health Housing Services Respite Services Self Direction Services Supported Education Environmental Modifications Respite Services TRAID Center Trauma Recovery Support Unique Perspectives 1. In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money for food? Yes No 2. In the last 12 months, has your utility company shut off your service for not paying your bills? Yes No Which service was shut off? What is the name of the provider that shut off your service? How much money is owed to this provider? 3. Are you worried that in the next 2 months, you may not have stable housing? Yes No Why are you worried? 4. Do problems getting child care make it difficult for you to work or study? (leave blank if you do not have children) Yes No 5. In the last 12 months, have you needed to see a doctor, but could not because of cost? Yes No Do you have health insurance? Yes No What is the name of the medical provider? 6. Are you in need of a primary care doctor? Yes No What is the name of your primary care doctor? 7. In the last 12 months, have you ever had to go without health care, medications, or groceries because you didn’t have access to transportation? Yes No 8. Do you ever need help reading hospital materials? Yes No 9. Are you afraid you might be hurt in your apartment building or house? Yes No 10. Are you in need of employment? Yes No 11. Do you need assistance obtaining and/or scheduling your COVID vaccination? Yes No 1. Do you have any concerns about making ends meet? Yes No 2. Do you have any concerns about your child's health insurance? Yes No 3. Do you have any concerns about having enough food? Yes No Have you ever been worried whether your food would run out before you got money to buy more? Yes No Within the last year has the food you bought ever not lasted and you didn’t have money to get more? Yes No 4. Do you have any concerns about poor housing conditions like mice, mold, cockroaches? Yes No 5. Do you have any concerns about being evicted or not being able to pay the rent or mortgage? Yes No 6. Do you have any concerns about your child’s educational needs? Yes No 7. Do you have any concerns about violence in your home? Yes No 8. What Hospital was your child born in? If your child was not born in the US, are you aware you may still be eligible for benefits? Yes No Not Applicable Regarding Question 11, would you like to have a social worker talk to you about possible benefits? Yes No Not Applicable 9. Are you the biological mother or father of this child? Yes No If you checked Yes to any boxes above, would you like to receive assistance with any of these needs? If so, someone from AccessCNY will be in touch with you to discuss further. Yes No Are any of your needs urgent? (For example: I don't have food tonight, I don't have a place to sleep tonight) Yes No Which of your needs are urgent? Additional Notes Δ
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