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Community Support Survey

Social Determinants of Health Survey

We are interested in your complete wellness. Please answer the questions below and we will do our best to provide support and guidance.

Fill Out the Form Below for Social Determinants of Health Survey

Are you at risk of losing safe and/or stable housing in the next few months?

Is the place you are staying currently unsafe or unstable?

Have you received shut-off notices from any utility companies in the past few months?

Have you worried about having enough food to feed your family in the past few months?

Have you missed medical appointment because of lack of transportation in the past few months?

Have you not bought medications or skipped medical appointments because of lack of income in the past few months?

Are you need of child or adult care?

Are you in need of legal help?

Are you experiencing difficulty in relationships? (partner, spouse, family member, etc.)

Have you felt unsafe, afraid, threatened, or hurt by someone currently in your life?

6 + 11 =

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