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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* 7. Date of Birth

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.

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

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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?

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

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

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

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

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

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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?

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

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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?

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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)?

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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?

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

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

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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.

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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?

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

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

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

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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)?

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

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

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