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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your date of birth?

Date

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* 4. What is your marital status?

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* 5. What is your race/ ethnicity?

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* 6. How did you find out about this program?

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* 7. What is your address?

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* 8. What is your phone number?

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* 9. Do you currently have health insurance?

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* 10. Do you currently have a medical home (medical provider who treats you for preventative and sick visits and helps coordinate specialty needs)?

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* 11. Have you seen your primary health care provider within the last year?

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* 12. Do you feel confident that you can manage and control your health concerns?

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* 13. Have you received any health-related services at City on a Hill in the past?

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* 14. Which of these options best describe your current employment status?

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* 15. Within the past year, have you or any of your family members (that you live with) needed assistance with the following resources? (check all that apply)

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* 16. Do you believe that you have the essential resources (such as food, housing, transportation, etc.) that are needed in order to be healthy?

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* 17. Have any of the following barriers kept you from attending medical appointments, meetings, work, and/ or school? (check all that apply)

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* 18. What is the highest level of schooling that you have completed?

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* 19. How strong is your sense of belonging in your community?

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* 20. How hopeful are you about the future?

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* 21. What is the best time to reach you?

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