Social Needs Assessment
Our aim is to guarantee that every client enjoys optimal health by addressing crucial needs such as access to adequate food, dependable transportation, secure housing, address substance use and mental health needs. We kindly request that you answer the following questions to aid us in comprehending your current needs, after which we will strive to link you with relevant local resources. Your responses to this assessment are optional and you do not have to answer every question. The answers on this assessment are completely confidential and will not be discussed with anyone outside of Jackson County Public Health.
Immediate Needs
Are any of your needs urgent? For example, you don't have food or need a safe place to sleep tonight.
Yes
No
Food
Within the past 6 months, did you worry that your food would run out before got money to buy more?
Yes
No
Within the past 6 months, did the food you bought just not last and you didn't have money to get more?
Yes
No
Housing & Utilities
Within the past 6 months, have you ever stayed outside, in a tent, in an overnight shelter, or temporarily in someone else's home (i.e. couchsurfing)?
Yes
No
Are you worried about losing your housing?
Yes
No
Within the past 6 months, have you been unable to afford utilities (such as heat or electricity) when they were really needed?
Yes
No
Transportation
Within the past 6 months, has a lack of transportation kept you from medical appointments or from doing things needed for daily living?
Yes
No
Alcohol & Substance Use
Within the past 6 months, have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)?
Yes
No
Within the past 6 months, have you used tobacco products (e.g. cigarettes, cigars, snuff, chew, electronic cigarettes)?
Yes
No
Within the past 6 months, have you used illegal drugs?
Yes
No
Mental Health
Within the past 6 months, have you felt down, depressed, or hopeless?
Yes
No
Other Resources
Are there other resources or support that our team can assist you with?
Yes
No
Connect with a Community Health Worker
JCPH Community Health Workers are available to meet with you, connect over the phone or email, or provide resources to help meet your needs.
Would you like to connect with a Community Health Worker to discuss the needs identified?
Yes
No
Are your needs emergent and you would like to meet with a Community Health Worker today?
Yes
No
Name
*
First Name
Last Name
What is your preferred contact information?
*
Please enter your phone number or email address, as well as any additional information the Community Health Worker may need, such as the best time(s) to reach you.
If you prefer a phone call, is it okay to leave a message/voicemail for you?
Yes
No
Submit
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