UNITED AND GUIDED COMPREHENSIVE NEEDS ASSESSMENT (UAG-CNA™)

Welcome to the United And Guided Comprehensive Needs Assessment - Thank you for choosing United And Guided.

This confidential assessment helps us understand your strengths, goals, health, and support needs so we can work together to develop a personalized care plan tailored to you and your family.

Our goal is to support your whole-person health—not just your medical needs.

We recognize that housing, employment, food, transportation, mental health, family support, education, and community connections all play an important role in your overall well-being.

The assessment typically takes 30–45 minutes to complete.

Privacy & HIPAA Notice

Your privacy is important to us.

This assessment is completed using United And Guided's HIPAA-compliant SurveyMonkey Enterprise account, protected by a Business Associate Agreement (BAA). Your information is encrypted, securely stored, and shared only with authorized members of your care team or as permitted by law.

Your information may be used to:

Develop your personalized care plan
Coordinate your healthcare and community services
Determine eligibility for programs
Connect you with resources that support your goals
Improve the quality of services we provide

Your Voice Matters

Every person's story is different.

We believe the people receiving services are the experts on their own lives.

This assessment gives you an opportunity to share your strengths, priorities, experiences, and goals so we can build a care plan with you—not for you.

Consent to Participate

Question Title

1. I understand that the information I provide may be used to:

Develop my personalized care plan

Determine my eligibility for programs and services

Coordinate my care with healthcare providers and community partners

Connect me with resources that support my goals

Contact me regarding appointments and follow-up services

Improve the quality of United And Guided's services.

(Required.)

I understand and agree.

I understand and choose to Opt-Out of the assessment.

Question Title

2. Do you voluntarily consent to participate in this assessment? (Required.)

Yes, I consent

No, I do not consent

Question Title

3. Preferred Contact Method (Required.)

Telehealth / Virtual Call

Text Message

In-Person Office Visit

Question Title

4. Electronic Signature (Required) - Please type your full legal name to acknowledge that the information you provide is accurate to the best of your knowledge and that you consent to participate in this assessment. (Required.)

Question Title

5. Assessment Date (Required.)

Date / Time

Date

UNITED AND GUIDED COMPREHENSIVE NEEDS ASSESSMENT (UAG-CNA™)

Question Title

Question Title

* 2. Do you voluntarily consent to participate in this assessment? (Required.)

Question Title

* 3. Preferred Contact Method (Required.)

Question Title

* 4. Electronic Signature (Required) - Please type your full legal name to acknowledge that the information you provide is accurate to the best of your knowledge and that you consent to participate in this assessment. (Required.)

Question Title

* 5. Assessment Date (Required.)

2. Do you voluntarily consent to participate in this assessment? (Required.)

3. Preferred Contact Method (Required.)

4. Electronic Signature (Required) - Please type your full legal name to acknowledge that the information you provide is accurate to the best of your knowledge and that you consent to participate in this assessment. (Required.)

5. Assessment Date (Required.)