Social Care Network – Free Food Program Survey

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.

I agree to continue and understand how my answers will be used. *

Medicaid

Do you have Medicaid? *

YesNo

Contact Information

First name *

Middle name

Last name *

Date of birth *

Phone *

Best time & days to reach you *

WeekdaysWeekendsAny day|MorningAfternoonEvening

Additional comment

Housing

Living situation *

Utility shut-off threatened? *

Problems with your home? * — check any that apply

Pests (bugs, ants, or mice)MoldLead paint or pipesLack of heatOven or stove not workingSmoke detectors missing or not workingWater leaksNone of the above

Food Security

Food ran out worry *

Food didn't last *

Transportation & Work

Transportation barrier? *

YesNo

Help finding/keeping work? *

Education & Safety

Help with school/training? *

YesNo

How often does anyone do the following? *

Physically hurt you

Insult / talk down

Threaten with harm

Scream or curse

Functional

Difficulty walking/stairs? (5+) *

YesNo

Difficulty dressing/bathing? (5+) *

YesNo

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