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Bridges to Care - We're Here to Support You

Thank you for taking a few moments to complete this intake survey. Your responses will help connect you—or someone you care about—to essential services like housing, food, healthcare, transportation, and more.

Our goal is simple: to make it easier for community members—especially those who have faced barriers or inequities—to access the support they need, when they need it. By sharing this information, you are helping us provide faster, more coordinated, and culturally responsive support through trusted, community-based health workers.

In the short term, this means quicker connections to services and more immediate help during times of need. Over time, this program is designed to empower individuals and families with the knowledge, tools, and confidence to navigate complex systems, advocate for themselves, and improve overall well-being.

Your voice matters. Every response helps us reduce gaps in services and build a more equitable, responsive system for everyone.

This survey should take about 5 minutes to complete. All information will be kept confidential and used only to connect you with the appropriate support.

Let’s get started.
1.Are you filling out this form for yourself, family member/friend, or for a client?(Required.)
2.What is your first and last name?
3.What year was the person who needs resources born?(Required.)
4.What is the best way to contact the person needing resources?(Required.)
5.At what email address or phone number would you like to be contacted at?(Required.)
6.What is the best time to reach you by phone?(Required.)
7.Please share the ZIP code of the person needing help(Required.)
8.How did you hear about our referral service?(Required.)
9.Does the person needing resources experience a disability?(Required.)
10.The Arc Lane County can help direct people to the following resources. Please indicate which supports the person needs:(Required.)
11.Has the person previously accessed resources or services to address this need?(Required.)
12.If yes, were those resources/services helpful?(Required.)
13.How urgently does the person need help?(Required.)
14.What is the person's primary language?(Required.)
Housing Stability
15.What is your current housing situation?(Required.)
16.In the past 12 month, have you worried about losing your housing?(Required.)
17.Do you currently have healthcare insurance?(Required.)
18.Do you have a primary care provider?(Required.)
19.In the past 12 month, did you delay or avoid medical care due to:(Required.)
20.Have you ever felt treated unfairly in a healthcare service setting?(Required.)
21.How would you rate your overall health?(Required.)
22.On a scale of 1-5, how supported do you feel in managing your health needs?(Required.)
23.Do you have someone you can trust to help you make healthcare decisions?(Required.)
24.How confident are you in understanding medical information provided to you?(Required.)
25.On a scale of 1-5, how much do social or financial challenges impact your health?(Required.)
Food Access & Nutrition
26.In the past 12 month, were you worried your food would run out before you had money to buy more?(Required.)
27.In the past 12 months, was there ever a time when the food you bought did not last and you did not have enough money to buy more?(Required.)
Transportation
28.Do you have reliable transportation to get to appointments and services?(Required.)
Income & Employment (this section is completely optional, and you do not have to share any information you are not comfortable providing. However, sharing this information may help us better understand your needs and connect you with the most appropriate resources or referrals more quickly.)
29.Current employment status:
30.Primary source of income:
31.In the past 12 month, have you had difficulty paying for:
Optional: Well - Being Snapshot
32.On a scale of 1-5, how would you rate your overall stress level?
33.On a scale of 1-5, how supported do you feel in meeting your family's needs?
34.Please share with us what your biggest barrier is right now.
35.How do you describe your race and/or ethnicity? Please select all that apply.