Assessment

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Assessment

Thank you for choosing to participate in our Health Screening Assessment. Your willingness to complete this assessment is greatly appreciated, as it plays a crucial role in helping us identify and understand your unique needs. By providing as much detail as possible, you enable us to accurately assess the various dimensions of your well-being.

Your participation in this screening allows us to provide tailored assistance and referrals to the right resources. By sharing comprehensive information, you enable us to create a holistic understanding of your situation, leading to more effective support and appropriate guidance. Each detail you provide helps us better serve you and work towards building a healthier, more resilient community.

Email *

Name *

Contact Number *

Is the number provided able to receive text?

Yes

Clear selection

Are you Hispanic or Latino? *

Yes

Prefer Not To Say

Which race(s) are you? Check all that apply *

Native Hawaiian

Black/African American

American Indian/Alaskan Native

Asian

White

Pacific Islander

Other:

Required

What language are you most comfortable speaking? *

Have you been discharged from the armed forces of the United States? *

Yes

Prefer not to answer

Family/Home

At our core, we are committed to ensuring that we leave no stone unturned when it comes to identifying the resources you may require. The assessment has been thoughtfully designed to assess and respond to the risks, assets, and experiences that you may be facing within the Northeast Georgia community. We aim to address a wide range of needs, including but not limited to food, shelter, transportation, financial support, and recovery support and more.

How many family members, including yourself, do you currently live with? *

What is your living situation today? *

I have a steady place to live

I have a place to live today, but I am worried about losing it in the future

I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)

Think about the place you live. Do you have problems with any of the following? CHOOSE ALL THAT APPLY *

Pests such as bugs, ants, or mice

Mold

Lead paint or pipes

Lack of heat

Oven or stove not workingx

Smoke detectors missing or not working

Water leaks

None of the above

Other:

Required

What is the primary address where you currently reside?
*

Please provide a physical address, including city and state, NO P.O Box

Food

Within the past 12 months, you worried that your food would run out before you got money to buy more.

Often

Sometimes

Never

Clear selection

Within the past 12 months, the food you bought didn't last and you didn't have money to get more..

Often

Sometimes

Never

Clear selection

Within the past 12 months, have you applied for SNAP Benefits?

Yes

Clear selection

If NO, please skip the next question.

Within the past 12 months, have you been notified of eligibility/ineligibility for SNAP benefits?

Yes, I've been notified of my eligibility.

Yes, I've been notified of my ineligibility.

No, I have applied but haven't received an update on my eligibility.

No, I've haven't applied.

Clear selection

Transportation

In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?
*

Yes

How do you currently commute to essential destinations such as work, school, medical appointments, and grocery stores?
*

Drive

Walk

Rideshare/Transportation Service

Ride with someone else

Do you have any specific requirements for transportation (e.g., wheelchair accessibility, specialized vehicles)?
*

Yes

Do you have access to a personal vehicle?
*

Yes

If yes, please provide details (e.g., make, model, condition).

Are there any financial constraints preventing you from accessing reliable transportation/ transportation services?

Yes

Clear selection

If yes, please provide details.

Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? Check all that apply.

Yes, it has kept me from medical appointments

Yes, it has gettingkeptmyme from medications non-medical meetings, appointments, work, or from getting things that

Utilities

What utilities (such as electricity, water, gas) do you currently have in your home?

Water

Gas

Electricity

All the above

None of the above

In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?
*

Yes

Utilities currently disconnected

Required

If you selected NO the previous question, please skip the next questions.

Please provide more details your utility services being shut off.

Are you able to afford your utility bills consistently?

Often

Sometimes

Never

Clear selection

Are there any energy-saving measures you have implemented to reduce utility costs?
*

Yes

I'm not sure

Safety/Emotional Support

Do you feel physically and emotionally safe where you currently live?
*

Never

Sometimes

Often

Always

Required

In the past year, have you been afraid of your partner or ex-partner?
*

Never

Sometimes

Often

Always

Required

How often do you see or talk to people that you care about and feel close to?
*

For example: talking to friends on the phone, visiting friends or family, going to church or club meetings

Never

Sometimes

Often

Always

Required

Are you currently in a situation where you feel unsafe or threatened by someone in your household or intimate partner?
*

Yes

Prefer not to say

Thank you once again for taking the time to complete this Health Screening Assessment. Your active participation makes a difference in our ability to identify and address your existing needs. Together, we can work towards connecting you with the right resources, providing the support necessary for your well-being and fostering a stronger community

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