• Patient survey

      Please take a minute to complete this form about areas where you may need information or support.

      We may not be able to address each item, but your input is a crucial part of identifying and creating relevant resources.

      In the past 12 months, have you been unable to get or pay for any of these supports when you really needed to?

      Choose all that apply:

      I have all the resources I need.I choose to not fill out this form today.Housing (rent, mortgage, shelter)Utilities (gas, electric, heat, water)EducationEyecareExercise ResourcesLegal HelpSupplies (clothing, diapers)Medication expensesFoodTransportationChild CareHealth InsuranceSocial Support Network (family, friends, religious group)Tech (Internet, phone, computer)DentalEmployment