At Great Mines Health Center, we want to make sure that we provide the best care and services possible to meet your needs. This information will help us determine if we need to add new services or programs to meet the needs of our patients. This information will be kept private and secure. Your decision to answer or to refuse to answer will NOT impact your ability to receive care. In many cases, this information will help us determine if you are eligible for any additional benefits, programs, or services.
NAME AND DOB REQUIRED 

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* 1. First Name

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* 2. Last Name

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* 3. DOB (date of birth)?

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* 4. Phone Number

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* 5. Are you Hispanic or Latino?

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* 6. Which race(s) are you?

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* 7. At any point in the past 2 years, has season or migrant farm work been your or your family’s main source of income?

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* 8. What Language are you most comfortable speaking?

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

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* 11. What is your current housing situation?

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* 12. Are you worried about losing your housing?

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* 13. What is the highest level of school that you have finished?

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* 14. What is your current work situation?

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* 15. During the past year, what was the total combined income for you and family members you live with?  This information will help us determine if you are eligible for any benefits.

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* 16. In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?

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* 17. Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

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* 18. 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)

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* 19. Stress is when someone feels tense, nervous, anxious, or can’t sleep at night because their mind is troubled. How stressed are you?

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* 20. In the past year, have you spent more than 2 nights in a row in jail, prison, detention center, or juvenile correction facility?

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* 21. Are you a refugee?

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

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

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