Name/Nombre
Name/Nombre
Address/Direccion *
Address/Direccion
Phone/Telefono
Phone/Telefono
Enter the phone number where you can best be reached.
Explain who referred you to FFRC services (e.g. Agency/DHS Worker)
Do you have a DHS Open Case/Tiene un Caso Abierto con DHS?
Please list all family members with their date of birth, self-identified gender and ethnicity, as well as, relationship to head of the household.
$
Where does your income come from? Full-time, part-time, side jobs...etc.
Please read paragraph and re-type name in the box below if you agree to the terms you have just read.
Name/Nombre *
Name/Nombre
Date/Fecha *
Date/Fecha
Services required/Servicio Necesario
Please check all that apply.
Health Families Screening - Access to Healthcare
Please fill out the bottom half to help us understand your family's health.
Does any family member experience difficulties with the cost of healthcare?
Please check one.
Does any member experience difficulty finding a medical provider?
Are all children fully immunized/Su hijo(s) son completamente immunizado?
Does every family member exercise regularly/ Todos en su familia hacen ejercico regularmente?
Is any family member experiencing difficulty managing stress?
Does everyone in the family eat healthy/Todos en su familia comen comida saludable?
Where do you see your family on this assessment scale?
Please check only one
Do you or your family members have any of the following insurance coverage?
Check all that apply
If you have children, are their immunizations up-to-date?
Please indicate your family's barriers/challenges to accessing insurance coverage and/or health care.
(Check all that apply)
How did you hear of our health services?