(ENGLISH-HC-PRE) Health Coaching Initial Intake and Pre-Assessment (July-2023-24)

CLIENT INFORMATION

Notes: Who is this form for? Women age 35-64 who are uninsured, under-insured and/or do not qualify for EWM.
*Please complete assessment form and submit.

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1. Date Completed this form with client: (Required.)

Date Completing this form:

Date

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2. Venue Name:

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3. Assessment Completed:

In person

At-home/virtual

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4. Name of Community Health Hub? (Required.)

Other (please specify)

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5. Client ID#: (Clients first 3 letters of last name and date of birth mmddyy; example: CRA020564)

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6. Birthdate:

Date / Time

Date

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7. Mailing Address:

Address:

City:

State:

ZIP:

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8. Contact Information:

Email:

Home Phone:

Work Phone:

Cell Phone:

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9. Preferred way of Contact?

Home Phone

Work Phone

Cell Phone

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10. Is it okay to text your cell phone?

Yes

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11. Are you of Hispanic/Latina(o) origin?

Yes

Unknown

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12. What is your primary language spoken in your home?

English

Spanish

Vietnamese

Other (please specify)

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13. What race or ethnicity are you? (check all boxes that apply)

American Indian/Alaska Native

Mexican American

Asian

Black/African American

White

Pacific Islander/Native Hawaiian

Unknown

Other (please specify)

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14. If American Indian/Alaska Native, what Tribe?

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15. Are you a Refugee?

Yes

Unknown

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16. Highest level of education completed:

<9th grade

Some high school

High school graduate of equivalent

Some college or higher

Don't Know

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17. If yes, where from?

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18. County of residence in Nebraska:

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19. Do you have a primary care physician?

Yes

Unknown

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20. Do you have Health Insurance?

Medicare (for people 65 and over) - Part A and B

Medicare (for people 65 and over) - Part A only

Medicaid (full coverage only)

Catastrophic Insurance Only

Health Marketplace

Private Insurance

No I don't have insurance

List Private Insurance:

Question Title

* 1. Date Completed this form with client: (Required.)

Question Title

* 2. Venue Name:

Question Title

* 3. Assessment Completed:

Question Title

* 4. Name of Community Health Hub? (Required.)

Question Title

* 5. Client ID#: (Clients first 3 letters of last name and date of birth mmddyy; example: CRA020564)

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* 6. Birthdate:

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* 7. Mailing Address:

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* 8. Contact Information:

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* 9. Preferred way of Contact?

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* 10. Is it okay to text your cell phone?

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* 11. Are you of Hispanic/Latina(o) origin?

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* 12. What is your primary language spoken in your home?

Question Title

* 13. What race or ethnicity are you? (check all boxes that apply)

Question Title

* 14. If American Indian/Alaska Native, what Tribe?

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* 15. Are you a Refugee?

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* 16. Highest level of education completed:

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* 17. If yes, where from?

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* 18. County of residence in Nebraska:

Question Title

* 19. Do you have a primary care physician?

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* 20. Do you have Health Insurance?

1. Date Completed this form with client: (Required.)

2. Venue Name:

3. Assessment Completed:

4. Name of Community Health Hub? (Required.)

5. Client ID#: (Clients first 3 letters of last name and date of birth mmddyy; example: CRA020564)

6. Birthdate:

7. Mailing Address:

8. Contact Information:

9. Preferred way of Contact?

10. Is it okay to text your cell phone?

11. Are you of Hispanic/Latina(o) origin?

12. What is your primary language spoken in your home?

13. What race or ethnicity are you? (check all boxes that apply)

14. If American Indian/Alaska Native, what Tribe?

15. Are you a Refugee?

16. Highest level of education completed:

17. If yes, where from?

18. County of residence in Nebraska:

19. Do you have a primary care physician?

20. Do you have Health Insurance?