Our free needs assessment is just the beginning of your headache free journey to wellness. Needs Assessment Intake Form. Name First Name Last Name Date of Birth MM DD YYYY Home Address If you have no current home address, please leave blank. Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### I consent to receive SMS from Hockanum Valley Community Council (HVCC). Reply STOP to opt-out; Reply AGENT for support; Message and data rates may apply; Messaging frequency may vary. * Opt-in, I consent to receiving SMS messages from HVCC. Opt-out, I do not consent to receiving SMS messages from HVCC. Email * Employment Status Full-Time Part-Time Self-Employed Unemployed Race White Black Asian American Indian/Alaskan Native Hawaiian/Islander Ethnicity Hispanic/Latinx Not Hispanic/Latinx Do you speak a language other than English as your primary language? Do you live on a fixed income? Yes No Unsure, rather disclose at appt. time Whether or not you are receiving any disability entitlement or benefit at this time, do you currently have a medical status the qualifies you as disabled? Yes No Unsure Dietary Needs Gluten Free Vegetarian Ketogenic/Low Carb Low Sodium Diabetic Do you need assistance or are you interested in any of the follow: SNAP, WIC, SSI/SSD Finding Housing Finding Employment Legal Aid or Services Obtaining Food Access to Medical Care Access to Mental Health or Substance Abuse Treatment Access to Transportation Tell us about yourself or what you are looking to address in this meeting. Thank you!
