Schedule Your Health Benefits Review

United And Guided - Health Need Assessment

Please complete the following assessment form before your scheduled appointment.

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* 1. First Name

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* 2. Last Name

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* 3. SMS Text Number

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* 4. Email

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* 5. Mailing address

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* 6. I am a...

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* 7. Date of Birth

Date / Time

Date

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* 8. Briefly describe your most urgent need?

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* 9. Which population(s) of focus most closely associate with your most urgent healthcare needs? Select all that apply.

Individuals or Families Experiencing Homelessness.

Individuals, Children, and Youth At Risk for Avoidable Hospital or Emergency Department
(ED) Utilization.

Individuals, Children, and Youth with Serious Mental Health and/or Substance Use Disorder
(SUD) Needs.

Individuals Transitioning from Incarceration.

Adults Living in the Community and At Risk for LTC Institutionalization.

Adult Nursing Facility Residents Transitioning to the Community.

Children and Youth Enrolled in California Children’s Services (CCS) or CCS Whole Child
Model (WCM) with Additional Needs Beyond the CCS Condition.

Children and Youth Involved in Child Welfare

Birth Equity Population of Focus

Black Fathers Inc. - Social and business support group for fathers of infant children.

Black Infant Health - Birth Education for expecting Black mothers.

None of the above

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* 10. Are you currently a Medi-Cal member?

Yes

No, because I have another health insurance provider.

No, because I am uninsured and would like to apply for Medi-Cal.

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* 11. Who is your health insurance provider? (N/A if uninsured)

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* 12. What is your health insurance card ID number (CIN) or Social Security Number (SSN)?

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* 13. What is your current Medi-Cal status?

Active

Non-Active

Fee-for-Service

Uninsured

Unsure

I'm not on Medi-Cal

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* 14. Please select the Medi-Cal benefits program(s) you are currently enrolled in?

Hospice

Medi-Cal and D-SNP Medicare

Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs)

Program for All-Inclusive Care for the Elderly (PACE)

Family Mosaic Project Services (FMPS)

Residing in an Intermediate Care Facility (ICF) or Subacute care facility.

I not enrolled in any of the Medi-Cal programs mentioned.

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* 15. Please select the 1915 Waiver program you are currently enrolled in:

Multi-purpose Senior Services Program (MSSP)

Assisted Living Waiver (ALW)

Home and Community-Based Alternatives (HCBA) Waiver

HIV/AIDS Waiver (ALW)

HBCS Waiver for Individuals With Developmental Disabilities (I/DD)

Self-Determination Program for Individuals with Developmental Disabilities

I am not enrolled in any of the 1915 Waiver programs mentioned

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* 16. Please select all wrap-around programs you are currently enrolled in:

California Children's Services (CCS)

Sacramento-County-Based Targeted Case Management (TCM)

Specialty Mental Health (SMHS) Targeted Case Management

Specialty Mental Health (SMHS) Intensive Care Coordination for Children (ICC)

Drug Medi-Cal Organized Delivery Systems (DMC-ODS)

Regional Center services

CCS Whole Child Model (CCS WCM)

Community Based Adult Services (CBAS)

In-Home Support Supports (IHSS)

Dual Eligible Special Needs Plans (D-SNPs)

D-SNP Look-Alike Plans

Medicare FFS

Medicare Advantage Plans

AIDS Healthcare Foundation Plans

Adult Full-Service Partnership (FSP)

I am not enrolled in any of the wrap-around programs mentioned.

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* 17. Please select any other program you are currently enrolled in:

Basic case management from a Managed Care Plan

Complex Case Management from a Managed Care Plan

California Community Transitions (CCT) Money Follows The Person (MFTP)

Residing and an Intensive Care Facility with an intellectual or developmental disability (I/DD)

I am not enrolled in any of the other programs mentioned.

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* 18. Are you and your family experiencing homelessness right now?

No, my family and I are not experiencing homelessness right now.

Yes, because I don't have a fixed, regular, and adequate nighttime residence.

Yes, because my primary residence is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings, including a car park, abandoned building, bus or train station, airport, or camping ground.

Yes, because I am living in a supervised, publicly or privately operated shelter designed to provide temporary living arrangements (including hotels and motels paid for by federal, state, or local government programs for low-income individuals or by charitable organizations, congregate shelters, and transitional housing).

Yes, because I am exiting an institution into homelessness (regardless of length of stay).

Yes, because I will immediately lose housing in the next 30 days.

Yes, because I am fleeing domestic violence, dating violence, sexual assault, stalking, and other dangerous, traumatic, or life-threatening conditions relating to such violence.

Yes, because I or my family member(s) is/are under 21 years of age.

Yes, because I am under 21 years of age and am sharing the housing of other persons (for example, couch surfing) due to loss of housing, economic hardship, or similar reason; am living in motels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; am living in emergency or transitional shelters; or am abandoned in hospitals (in hospital without a safe place to be discharged to.)

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* 19. Do you have any of the following complex physical, behavioral, or developmental health need(s) with inability to successfuly self-manage?

No, I do not have any complex physical, behavioral, or developmental health needs with an inability to successfully self-manage.

Asthma

Chronic kidney disease

Chronic liver disease

Chronic obstructive pulmonary disease (COPD)

Congestive heart failure (CHF)

Coronary artery disease

Dementia requiring assistance with instumental activities of daily living (IADLs)

Diabetis (Insulin-dependent) poorly controlled

Hepatitis-C

History of stroke or heart attack

HIV

Hypertension (poorly controlled)

Pregnant or Post-partum

Traumatic brain injury (TBI)

Bipolar disorder

Major depressive disorder

Psychotic disorders, including schizophrenia

Substance use disorder

Intellectual/developmental disability

Other (please specify)

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* 20. Are you an individual, child, and/or youth at risk for avoidable hospital or emergency department (ED) utilization?

No, I am not an individual, child, and/or youth at risk for avoidable hospital or emergency department (ED) utilization.

Yes, because I am over 21 years of age and have had 5 or more emergency department visits in the last 6 months that could have been avoided with appropriate outpatient care or improved treatment adherence.

Yes, because I am over 21 years of age and have had 3 or more unplanned stays (hospital admissions and/or short-term skilled nursing facility) in the last 6 months that could have been avoided with appropriate outpatient care or improved treatment adherence.

Yes, because I am under 21 years of age and have had 3 or more emergency department visits in the last 12 months that could have been avoided with appropriate outpatient care or improved treatment adherence.

Yes, because I am under 21 years of age and have had 2 or more unplanned stays (hospital admissions and/or short-term skilled nursing facility) in the last 12 months that could have been avoided with appropriate outpatient care or improved treatment adherence.

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* 21. Are you an adult individual, child or youth any of the following complex physical, behavioral, or developmental health need(s) with serious mental health and/or Substance Use Disorder (SUD) needs?

No, I do not have any complex physical, behavioral, or developmental health needs with serious mental health and/or Substance Use Disorder (SUD) needs.

Asthma

Chronic kidney disease

Chronic liver disease

Chronic obstructive pulmonary disease (COPD)

Congestive heart failure (CHF)

Coronary artery disease

Dementia requiring assistance with instumental activities of daily living (IADLs)

Diabetis (Insulin-dependent) poorly controlled

Hepatitis-C

History of stroke or heart attack

HIV

Hypertension (poorly controlled)

Pregnant or Post-partum

Traumatic brain injury (TBI)

Bipolar disorder

Major depressive disorder

Psychotic disorders, including schizophrenia

Substance use disorder

Intellectual/developmental disability

Other (please specify)

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* 22. Are you a youth or adult that participates in, or obtains services through Specialty Mental Health Services (SMHS) delivered by a Mental Health Plan (MHP)?

Yes

Unsure

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* 23. Are you a youth or adult that participate in, or obtain services through The Drug Medi-Cal Organized Delivery System (DMC-ODS) or the Drug Medi-Cal (DMC) program?

Yes

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* 24. Are you experiencing one or more of the following complex social factors?

Lack of access to food

Lack of access to stable housing

Inability to work or engage in the community

4 or more adverse childhood experiences (ACEs) based on screening

Former foster youth

History of recent contacts with law enforcement related to mental health and/or substance use symptoms

Other (please specify)

None of the above

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* 25. Are you experiencing any of the following trauma?

I am at high risk for institutionalization, overdose, and/or suicide

I use crisis services, emergency rooms, urgent care, or inpatient stays as the primary source of care

I've had 2 or more emergency department visits due to serious mental health or Substance Abuse Disorder in the past 12 months

I've had 2 or more hospitalizations due to serious mental health or Substance Use Disorder in the past 12 months

None of the above

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* 26. Are you a youth or adult transitioning from a correctional setting (for example prison, jail, or youth correctional facility) or transitioned from a correctional setting within the last 12 months.

No, I am not transitioning from a corrective setting.

Yes, and I have a mental illness.

Yes, and I have a Substance Use Disorder (SUD).

Yes, and I have a chronic condition or significant non-chronic clinical condition.

Yes, and I have an Intellectual or Developmental Disability (I/DD).

Yes, and I have a traumatic brain injury.

Yes, and I have HIV/AIDS.

Yes, and I am pregnant or postpartum.

Yes, but I do not have any of these conditions.

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* 27. Are you living in the community but require lower-acuity skilled nursing, such as time-limited and/or intermittent medical and nursing services, support, and/or equipment for prevention, diagnosis, or treatment of acute illnes/injury?

Yes

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* 28. Are you able to reside continuously in the community with wraparound supports?

Yes

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* 29. Select the complex social or environmental factors that are influencing your health.

I need assistance with activities of daily living.

I have communication difficulties.

I do not have access to food.

I do not have stable housing.

I live alone.

I need a conservatorship or guided decision-making.

I have poor or inadequate caregiving which may appear as a lack of safety monitoring.

Other (please specify)

None of the above

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* 30. Are you currently residing in an adult nursing facility who is interested in moving out of the institution?

No, I am not an adult nursing facility resident transitioning to the community

Yes, and I am likely to do this successfully because I am able to reside continuously in the community.

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* 31. Do you have, or are you a youth enrolled in California Children's Services (CSS) or CCS Whole Child Model (WCM)?

Yes

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* 32. Are you a child or youth or have a child or youth involved in Child Welfare?

No, I am not a child or youth, nor do I have a child or youth involved in Child Welfare.

I am, or have a youth under age 21 currently receiving foster care.

I am, or have a youth under age 21 that previously received foster care in California or another state within the last 12 months.

I am, or have a youth that has aged out of foster care up to age 26 (having been in foster care on my/their 18th birthday or later) in California or another state.

I am, or have a youth under age 18 that is eligible, or a participant in the California Adoption Assistance Program.

I am, or have a youth under age 18 that is currently receiving or has received services from California's Family Maintenance program within the last 12 months.

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* 33. Are you an adult or youth who is pregnant or postpartum and is subject to racial and ethnic disparities?

No, I am not a pregnant or postpartum adult or youth subject to racial and ethnic disparities.

Yes, because I am a member of the Black community.

Yes, because I am a member of the American Indian and Alaska Native community.

Yes, because I am a member of the Pacific Islander community.

Yes, because I am a member of an ethnic group I believe is identified in the most recent California Department of Public Health (CDPH) data on maternal morbidity and mortality.