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Imani Clinic Basic Needs Assistance Form
If you are a Imani Clinic Patient or from the Oak-park community/greater Sacramento area facing challenges accessing adequate food, stable housing, or financial resources, please complete this form.
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First Name
*
Your answer
Last Name
*
Your answer
Phone Number
*
Your answer
What circumstances are impacting you and/or your family?
*
Your answer
How can basic needs resources (food, housing, financial services) help you and/or your family?
*
Your answer
If you would like to receive an Imani Basic Needs care package, please enter your address below.
Your answer
Would you like to sign-up for Cal-Fresh?
Yes
No
Maybe
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By entering my initials below, I certify that the information I provided is true and complete to the best of my knowledge. If this application is approved, I understand that false or misleading information will result in the cancellation of privileges granted by the Imani Clinic Basic Needs Specialty Clinic.*
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