Monday – Friday: 8:00 AM - 4:30 PM
Saturday and Sunday: Closed
Closed on Major Holidays

SDOH Form

In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food?

In the last 12 months, has the electric, gas, oil, or water company threatened to shut off your services in your home?

Are you worried that in the next 2 months, you may not have stable housing?

Do problems getting childcare make it difficult for you to work or study?

In the last 12 months, have you needed to see a doctor, but could not because of cost?

In the last 12 months, have you ever had to go without health care because you didn’t have a way to get there?

Do you ever need help reading hospital materials?

Do you often feel that you lack companionship?

Are any of your needs urgent? For example: I don’t have food tonight, I don’t have a place to sleep tonight

If you checked YES to any boxes above, would you like to receive assistance with any of these needs?