Uninsured Individual -- Data Collection Form

If you are seeking treatment assistance but do not have health insurance coverage, please complete this form. Providing this information will enhance our understanding of the obstacles faced by uninsured individuals and how Project HEAL might play a role in overcoming those obstacles, now or in the future. 

Please provide your contact information. 

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* 1. Please provide your contact information. 

What is your age?

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* 2. What is your age?

What is your race/ethnicity? Check all that apply.

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* 3. What is your race/ethnicity? Check all that apply.

Are you:

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* 4. Are you:

Do you consider yourself to be:

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* 5. Do you consider yourself to be:

How many people live in your household, including you?

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* 6. How many people live in your household, including you?

How many legal dependents do you support?

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* 7. How many legal dependents do you support?

What is your annual household income before taxes?

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* 8. What is your annual household income before taxes?

What is your diagnosis? Check all that apply.

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* 9. What is your diagnosis? Check all that apply.

What type of treatment are you seeking? Check all that apply.

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* 10. What type of treatment are you seeking? Check all that apply.

Do you receive SSI?

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* 11. Do you receive SSI?

Do you receive SSDI?

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* 12. Do you receive SSDI?

Are you legally disabled?

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* 13. Are you legally disabled?

Are you a student?

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* 14. Are you a student?

Have you applied for coverage under your parent’s health insurance policy? Note: Disabled adult children can remain on their parent’s health insurance past the age of 25 if the insurance company is provided with appropriate documentation.

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* 15. Have you applied for coverage under your parent’s health insurance policy? Note: Disabled adult children can remain on their parent’s health insurance past the age of 25 if the insurance company is provided with appropriate documentation.

1.     Have you applied for health insurance through your state’s ACA marketplace?

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* 16. 1.     Have you applied for health insurance through your state’s ACA marketplace?

If you answered "Yes" to the previous question, why didn't you purchase a plan through your state's ACA marketplace? Check all that apply.

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* 17. If you answered "Yes" to the previous question, why didn't you purchase a plan through your state's ACA marketplace? Check all that apply.

Have you applied for Medicaid?

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* 18. Have you applied for Medicaid?

If you answered "Yes" to the previous question, why didn't you qualify for Medicaid? Check all that apply.

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* 19. If you answered "Yes" to the previous question, why didn't you qualify for Medicaid? Check all that apply.

Is there anything else you would like us to know about you or your situation?

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* 20. Is there anything else you would like us to know about you or your situation?

If Project HEAL is unable to provide a grant to you, is there anything else we can do to support you during your recovery journey?

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* 21. If Project HEAL is unable to provide a grant to you, is there anything else we can do to support you during your recovery journey?

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