Community Connection Center | Driscoll Health Plan

This questionnaire collects information about your family. Please read and answer every question. All information provided will be treated in strict confidence and will not be made available to any other source without your approval. All data gathered will be protected under the HIPPA privacy act.

* = required

Date

Select the Community Connection Center location you visited.*

City where you live:*

Zip code:*

What is your age?*

Are you currently pregnant?*

Yes
No

Do you have children under 18 years of age?*

Yes
No

How many?*

Are you the child(ren)'s primary caretaker?*

Yes
No

How many people live in your home?*

Do you or someone in your home have any of the following?

Special needs
Behavioral health
Chronic illness

Who has special needs?*

Me
A household member
A household member and me

Who has behavioral health issues?*

Me
A household member
A household member and me

Who has chronic illness?*

Me
A household member
A household member and me

Do you or a household member currently have any of the types of assistance below? Please select if any apply.*

"Other" is selected, please specify:*

Are you in need of a referral for any of the following? Please select if any apply.

The Community Has a Referral Sheet where we can connect you to services. Ask the Community Room Staff.

"Other" is selected, please specify:*

Are you or anyone in your home a migrant worker?*

Yes
No

What is your employment status?*

Fulltime
Part time
Not working
Retired

What is your housing status?*

Own
Rent
Staying with friends/family
Homeless or displaced

What language do you speak at home?*

English
Spanish
Both English/Spanish
Other

"Other" is selected, please specify:*

Would you benefit from any of the following Health Topics or Social Programs? Please select if any apply.

"Other" is selected, please specify:*

Did you receive a reference sheet with community program information from the staff that helped you today?*

Yes
No

Please ask the staff to provide you with a reference sheet with community program information. This sheet will have information on other programs which can help you with services.

Who referred you to Driscoll Community Room?*

Family/Friend
Organization

"Organization" is selected, please specify:*

What other items/supplies would you like to see in community room?