Connection 4 Wellness Enrollment

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Please complete this enrollment form. It will give us basic information that will help us know where we can offer immediate and ongoing support to elevate your wellness and support your mental and emotional health.

IMPORTANT: Please schedule your enrollment meeting after completing this form. If you do not meet with us, your enrollment will not be processed.

Please note that Connection 4 Wellness services are not for basic needs emergencies, mental health emergencies, or other time-sensitive situations.

Please tell us about your needs. (check all that apply) *

I need to find a mental/emotional health provider (counselor, therapist, psychologist, grief coach, life coach, etc)

I already have a mental/emotional health provider and would like reimbursement towards my out of pocket costs.

I need to build my social support system by participating in more community events, learning, and volunteer opportunities. (Subscribe to our Connection 4 Wellness newsletter)

I am interested in learning about my options for health insurance. ( Referral to ASPIN Health Navigator)

I need basic needs resources, such as information about rental assistance, utility assistance and food. (You will meet with the program coordinator to learn how to utilize the Indiana 2-1-1 website)

I need career and financial literacy resources. (Referral to IMPACT program, Center for Working Families, Dress for Success Indianapolis, etc)

I want information about the Center of Wellness for Urban Women's Power of Retreat program, which is a program for women and their families to have space to address trauma, learn coping tools, and build social networks for support and understanding.

I want information about the Center of Wellness for Urban Women's Sisters Together: Move More, Eat Better program, which was designed specifically to meet the needs of women to improve their overall health and wellbeing through comprehensive health education, screenings, support, and more.

I want information about the Centers of Wellness for Urban Women's Young Women's Health program, a program focusing on the special whole health needs of women ages 18-24.

I want information about the Center of Wellness for Urban Women's Neighborhood Food Champions program, which supports empowered community residents working to address food access in their neighborhoods. Each “Champion” receives comprehensive training and mentorship, to develop a sustainable community project, as well as a project award.

Required

Do you consent to the Centers of Wellness for Urban Women collecting your information, storing it securely and sharing it with your chosen providers and community resources? (Please note we will ONLY share with those you request, and an additional Release of Information may be needed to work with specific partners/resources ) *

Yes

Are you interested in working with our program's mental health partners? *

Yes, I would like to work with Rae Karim at Good Grief Now! Self-pay only, no insurance accepted (Not currently taking CWUW funded clients)

Yes, I would like to work with Kamri McDaniel, LCSW at Creating Space for You, LLC. Insurance accepted: Anthem, United Health Care, and Cigna (Not currently taking clients)

Yes, I would like to work with Hope Moreland, LCSW. Insurance accepted: Medicaid/HIP, Anthem, Cigna, and Aetna

Yes, I would like to work with Tanisia Crowder, LCSW. Insurance accepted: Anthem, United Healthcare, UMR and Cigna

Maybe, but I need to know more about them. (This will be discussed in your enrollment meeting)

No, I have my own provider.

No, I am not interested in mental health care at this time.

First name *

Last name *

Email *

Phone *

Preferred Method of Communication *

Text

Required

How did you hear about Connection 4 Wellness? *

I found CWUW's information on my own. (website, social media, community event, etc)

Friend/Family Member/Co-Worker, etc- Someone I know told me about CWUW

I was referred by a community organization or other resource.

If you were referred by another community organization or resource, which one?

County of Residence *

Marion

Other:

Zip Code *

Gender *

Woman

Man

Transgender Man

Transgender Woman

Non-binary

Other:

Pronouns

She/her/hers

They/them/theirs

He/him/his

Other:

Race *

African American or Black

American Indian or Alaskan Native

Asian

Caucasian/White

Native Hawaiian/Other Pacific Islander

Two or More Races

Other:

Ethnicity *

Hispanic

Non-Hispanic

Age *

Marital Status *

Single (Never Married)

Domestic Partner

Married

Separated

Divorced

Widowed

Family Size: How many adults (over 18) live in the household? *

Family Size: How many children (under 18) live in the household? *

Annual Household Income (from all sources for all adults) *

Employment Status *

Employed Full-time (35 hrs or more per week)

Employed Part-time (less than 35 hrs per week)

Unemployed (seeking employment)

Not in the workforce (retired, unable to work, etc)

Entrepreneur/Self-Employed/Independent Contractor/Gig Worker

Required

Education Level *

Less than High School

High School/GED/HSE

Technical Degree/Certification

Some College

Two Year Degree

Four-Year Degree

Master's Degree

Doctorate Degree

Housing Situation *

Rent

Own

Stays with family/friends

Transitional housing

Shelter care

Unhoused

Other:

Required

Transportation Access *

I have access to transportation. (I drive, have access to public transportation, can easily get a ride with someone, etc)

I do not have access to transportation. (I do not drive, do not have access to public transportation, cannot easily get a ride with someone, etc)

Other:

Do you currently receive SNAP benefits? *

Yes

Are you a veteran of the U.S. Armed Forces? *

Yes

Do you currently have health insurance? *

Yes

Other:

If yes, who is your insurance carrier? (If no, type N/A) *

Currently, how would you describe your emotional/behavioral/mental health? *

Excellent

Good

Fair

Poor

I don't know

If you are in the process of searching for a mental health provider, please describe your perfect provider. (You can discuss race/age/gender, specialties, etc)

Have you in the past, or are you currently receiving any type of mental health care or supports? *

Licensed therapy or counseling

Life coaching

Support group(s)

Mental health education (events, series, etc)

Other:

Required

How comfortable and knowledgeble do you feel when discussing mental, emotional, behavioral health topics with the people in your life?
*

Very comfortable and knowledgeable

Somewhat comfortable and knowledgeable

Not at all comfortable or knowledgeable

Comfortable, but not knowledgeable

Knowledgeable, but not comfortable

Other:

What is going well in your life right now? *

What are the biggest stressors in your life right now? *

Have you attended any events (virtual or in-person) hosted by our organization (The Centers of Wellness for Urban Women, Inc) this year? If so, please name/describe event.

Please provide us with any additional information you think we may need to process your enrollment.

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