Date

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   

In the last 12 months, has your utility company shutoff your service for not paying your bills?  
Yes    No   

Are you worried that in the next few months, you may not have stable housing?  
Yes    No   

Do problems getting care for a family member (child care, or daycare for an older adult) make it difficult for you to work or study?  
Yes    No   

In the last 12 months, have you needed to see a doctor, but could not because of cost?  
Yes    No   

In the past 12 months, have you ever had to go without healthcare because you did not have transportation to get there?  
Yes    No   

Do you ever need help reading our clinic material?  
Yes    No   

Are you afraid that you might be hurt in your home?  
Yes    No   

If you answered yes to any of the above questions, would you like to receive assistance with any of these needs?  
Yes    No   

Are any of the above needs urgent?  
Yes    No   

Code: z71.89

If you answered yes to any of the above questions one of our care managers will reach out to you to provide assistance.

If at any time you do experience a new need in any of these areas please alert your provider or call our office and speak with one of our care managers.