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Social Care Network – Free Food Program Survey

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Consent

This survey helps us understand needs that may affect your access to services. We may share your answers with your healthcare providers and health plan so they can check if you qualify for free non-medical services.

Medicaid

Do you have Medicaid? *

Contact Information

Best time & days to reach you *

Housing

Problems with your home? * — check any that apply

Food Security

Transportation & Work

Transportation barrier? *

Education & Safety

Help with school/training? *
How often does anyone do the following? *

Functional

Difficulty walking/stairs? (5+) *
Difficulty dressing/bathing? (5+) *
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