Barbershop

Interest
Are you interested in the Wellness Clinic?
If no, could you share your reason?
We have a few questions to ask you regarding your health and social needs to help us provide you the best service. Our discussion and your responses are strictly confidential. At any time, you may choose not to answer any question or discontinue participation, the clinic is completely confidential and will not cost you any money. Are you willing to sign this consent?
Please type your Full Name here to confirm your consent to participate.
Barber:
Other Barber:
Demographics
First Name
Last Name
Phone Number
Do Not Call
Email Address
Do Not Email
Preference for Communication
Best Time to Call
Zip Code of Residence
Preferred Language
Are you Hispanic or Latino?
Which race(s) are you? Select all that apply.
Age Range
What pronouns do you prefer?
Have you been discharged from the armed forces of the United States?
Health
In general, would you say your health is:
Are you currently enrolled in a health insurance plan?
Do you know who your insurance is with?
May we connect you with a care coordinator from your insurance plan?
Do you have a primary care provider?
If yes, do you know what their name is? Or where they are located?
Would you like assistance connecting to a primary care provider, doctor?
Do you have any preferences in where they are located?
We can offer a number of health screenings today. Please let me know which of these you are interested in?
Housing
How many family members, including yourself, do you currently live with?
What is your housing situation today?
Are you worried about losing your housing?
Financial
What is your highest level of school that you have finished?
What is your current work situation?
During the past year, what was the total combined income for you and the family members you live with? This information will help us determine if you are eligible for any benefits.
In the past year, have you or any of the family members you live with been unable to get any of the following when it was really needed? Check all that apply.
Has lack of transportation kept you from attending medical appointments, meetings, work, or from getting things needed for daily living? Check all that apply.
Social and Emotional
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)
Stress is when someone feels tense, nervous, anxious, or canâ€™t sleep at night because their mind is troubled. How stressed are you?
Do you feel physically and emotionally safe where you currently live?
Priorities
Are any of your needs urgent?
Of the previous questions and topics, are there any areas you would like to receive assistance or support?
If yes, which would you like to start with?
How ready are you to address this?
What might be get in the way of your ability to start to address this?

Location

Contact Us

Subscribe Today!