Welcome to the Clinic Food Box Program at the Sanford Substance Use Disorders Clinic! The Clinic Food Box Program is a program of the Great Plains Food Bank.
Before we get started, we have just a few quick questions. The following questions allow us to better serve our neighbors across ND and Clay County, MN. By continuing with this intake form, you are confirming that you are entering this information voluntarily and that it is accurate to the best of your knowledge.
Information will be used by the Great Plains Food Bank to make program improvements and analyze the impact of this Clinic Food Box program on the health of patients.

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* 1. Have you visited any community food pantry in the last six months?

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* 2. Have you received food box(es) from this Food Box Program at any time since the beginning of this month?

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* 3. How old are you?

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* 4. What ZIP Code do you live in? (enter 5-digit ZIP code; for example, 00544 or 94305)

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* 5. How many children (ages 0-17) live in your household? Enter 0 if there are none.

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* 6. How many people between the ages of 18-59 live in your household? Include yourself if you fall between this age range in your household. Enter 0 if there are none.

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* 7. How many people ages 60 and older live in your household? Include yourself if you fall between this age range. Enter 0 if there are none.

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* 8. Do you or anyone in your household receive SNAP (food stamps) benefits?

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* 9. FOR STAFF ONLY:

The following two questions are required in order for the Food Box visit to be completed.

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* 10. Were any of the following items distributed to the family today? Check all boxes that apply:

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* 11. How many boxes were distributed for this patient's household?

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