Unlock Up to $5,000 in Free Medi‑Cal Help

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

READ: Answer a few quick questions to see if Medi-Cal may help with housing, food, mental health, bills, and other support. We use this form to look for every kind of help you may be able to get — fast.

This form is for people on Medi-Cal who are dealing with problems like housing, health, money, court, jail, prison, or other system issues.

There are no right or wrong answers. Please be honest. The more we know, the more help we may be able to find for you. If you are going through a lot right now, that may actually help us connect you to more services.

Even if you think you do not qualify, fill it out anyway. Many programs cover more people than most think. For example, if you are staying with friends or family, sleeping on couches, or moving from place to place, that may count as homeless for some programs.

WHO CAN FILL IT OUT: You can fill it out for yourself. A parent or guardian can fill it out for a child under 18. Family can fill it out for someone in jail or prison who will be released soon.

Send one form for each person. If more than one person in your home has Medi-Cal, each person needs their own form.

IMPORTANT: Please answer your phone. If our care team calls and cannot reach you, your help may be delayed. Most people hear from us within 72 hours, so keep your phone on and close by.

You Might Qualify for Major California Benefits — And Not Even Know It!

Get the Help You Deserve!

First Name *

Last Name *

Date of Birth *

YYYY

Gender *

Email

(REQUIRED FOR UPDATES - NO FOLLOW UP WITHOUT IT)

Phone Number

(Must be valid to qualify.) Incorrect info is an automatic disqualify.

Zip Code

(Where You Stay)

Medi-Cal Plan

(Must Be Active)

🏠 HOMELESSNESS / HOUSING INSTABILITY

(Check all that apply)

I am staying in a car, RV, tent, or on the street.

I am "couch-surfing" or staying with friends/family because I lost my housing.

I have an eviction notice or will lose my housing within the next 14 days.

I am living in a shelter or transitional housing

I am living in a motel/hotel with no other housing option

I am fleeing domestic violence and have nowhere safe to stay

I just left jail, hospital, or foster care with no place to go

I am living in a garage, shed, or space not meant for housing

My housing is unsafe, overcrowded, or I lack basic facilities

I live in a neighborhood with high violence or crime that makes it hard to stay safe or healthy.

🧠 SERIOUS MENTAL ILLNESS (SMI) - Adults 18+

(Check all that apply)

Major Depressive Disorder (or diagnosis that has impaired functioning in past year)

Bipolar Disorder (I or II)

Generalized Anxiety Disorder (substantially interferes with daily life)

Panic Disorder

Social Anxiety Disorder

PTSD or Complex PTSD (Post-Traumatic Stress Disorder)

Schizophrenia or Schizoaffective Disorder

OCD (Obsessive-Compulsive Disorder)

Eating Disorder (Anorexia, Bulimia, Binge Eating)

Any mental health condition that makes it hard to work, maintain relationships, or care for myself

💊 SUBSTANCE USE DISORDERS

(Check all that apply)

Alcohol use that affects my health, housing, or relationships

Drug use that affects my health, housing, or relationships

I am interested in substance use treatment or recovery support

I have overdosed in the past year or at a high risk of overdose.

I use substances to manage pain, stress, or trauma

The area where I live makes my recovery harder because it reminds me of my past drug use or has triggers.

Alcohol (beer, wine, liquor).

Cannabis (weed, THC vapes, edibles).

Inhalants (sniffing or huffing paint, glue, aerosol cans, gasoline, nitrous, etc.).

Opioids (heroin, fentanyl, street “blues,” and prescription pain pills like oxycodone, hydrocodone, morphine).

Stimulants (meth, cocaine, crack, prescription stimulants like Adderall or Ritalin when misused)

Sedatives, hypnotics, and anxiety pills (Xanax, Valium, Ativan, sleeping pills, barbiturates).

Hallucinogens (LSD/acid, mushrooms, PCP, ecstasy/MDMA, ketamine, other “party drugs”

Over-the-counter meds when misused (cough syrup, cold meds, “triple C’s,” etc.)

Smoke Shop (K2/Spice, bath salts, kratom shots, tianeptine/‘gas station heroin,’ phenibut, delta‑8, etc.).”

🤰 PREGNANCY & POSTPARTUM

(Check all that apply)

I am currently pregnant

I have given birth within the last 12 months

I had a miscarriage or pregnancy loss in the past 12 months

I am pregnant and experiencing homelessness or housing instability

I am pregnant and have a substance use disorder or mental health condition

🚑FREQUENT HOSPITAL & EMERGENCY ROOM VISITS

(Check all that apply)

I have visited the Emergency Room 2+ times in the past year

I have been hospitalized 2+ times in the past year

I frequently use the ER for non-emergency care

I have difficulty accessing regular medical care

I do not have a primary care doctor or regular provider

I have difficulty getting to medical appointments (transportation barriers)

I have trouble managing or affording my prescription medications

I am at risk for institutionalization or hospitalization due to my health or living situation

🏭 CARE TRANSITIONS & POST-HOSPITAL SUPPORT

(Check all that apply)

I just left the hospital and need help with care or recovery at home

I need support managing my medications after hospital discharge

I need help getting to follow-up appointments after being in the hospital

I don't have a discharge plan or understand my post-hospital care instructions

🤒 CHRONIC HEALTH CONDITIONS

(Check all that apply)

I have 2 or more chronic health conditions (diabetes, heart disease, asthma, etc.)

I have difficulty managing my health conditions

My health conditions affect my daily life and ability to work

I have obesity and it affects my health, mobility, or ability to work or stay housed.

I have pre-diabetes or diabetes that is hard to control.

I have heart disease, high blood pressure, or high cholesterol.

My weight or other physical health conditions make it hard to work or do daily tasks.

I heavy smoke/chew tobacco or vape nicotine (COPD, cardiovascular risk)

🧩 INTELLECTUAL/DEVELOPMENTAL DISABILITIES (I/DD)

Check all that apply

I have Autism Spectrum Disorder (ASD) + another qualifying condition

I have Intellectual Disability or developmental delays

I have a developmental condition that affects my daily living

I have cerebral palsy

I have epilepsy

👶 CHILDREN & FAMILY HEALTH

(Check all that apply)

This child/youth has serious emotional disturbance (SED) or behavioral health needs

This child is involved with Child Welfare/Foster Care system

This child has special health care needs requiring complex care coordination

My family has multiple complex needs affecting health and stabilityADDITIONAL ECM

⚠️ SAFETY CONCERNS

(Check all that apply)

I have had thoughts of wanting to die or hurt myself (suicidal thoughts) in the past year.

I have attempted suicide or harmed myself in the past year.

I feel unsafe where I live because of someone I live with or see regularly.

I am being controlled, threatened, or hurt by a partner, family member, or someone I know.

💼 WORK, FUNCTIONING & DAILY LIVING

(Check all that apply)

My health or mental health makes it hard to work or keep a job.

I lost my job or work fewer hours because of my health, caregiving, or mental health.

My health or mental health puts my housing at risk (can't pay rent, conflicts with landlord/roommates, or difficulty following rules).

I need help with daily tasks like managing medications, transportation, or appointments.

🍎 FOOD INSECURITY / FOOD ENVIRONMENT

(Check all that apply)

I often skip meals or eat less because I cannot afford enough food.

I live in an area with no easy access to fresh fruits and vegetables (food desert).

Most of my meals come from fast food, gas stations, or convenience stores.

I do not have a working kitchen, fridge, or place to store and cook food.

My health conditions (like diabetes, heart disease, or obesity) are hard to manage because of my diet or food access.

🤝 SOCIAL ISOLATION & SUPPORT NEEDS

(Check all that apply)

I feel lonely or isolated from family, friends, or community

I have no one to call if I need help or support

I have difficulty communicating or connecting with others due to language barriers

I am a caregiver for someone and feel overwhelmed or isolated

I have experienced elder abuse or neglect

⚖️ JUSTICE SYSTEM INVOLVEMENT

(Check all that apply)

I have been recently released from jail or prison (past 12 months)

I am currently on probation or parole

I am facing charges or have pending court dates that stress me out

I have justice system involvement that affects my housing, employment, or health

I will be released from jail or prison soon and need help with housing or healthcare

I am in jail waiting for my trial or court date

I am out on bail or released while waiting for my court date

I have been ordered to do community service

♿️ PHYSICAL DISABILITY & MOBILITY BARRIERS

(Check all that apply)

I have difficulty walking, moving around, or using stairs

I have a physical disability that limits my daily activities

I need help with mobility or assistive devices (wheelchair, walker, etc.)

🏳️‍🌈 IDENTITY & CULTURAL FACTORS

(Check all that apply)

I am LGBTQ+ and my identity has caused conflict or made it unsafe to stay with my family

My language or cultural background makes it hard to get healthcare or understand the healthcare system

I am a black, Native American, or Pacific islander woman who is pregnant.

Requested Follow-Up *

I agree that Help Is Hope can contact me and share this information with care partners to help connect me to services. My information will remain confidential. *

Agree

Required

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Help Is Hope Foundation.

Does this form look suspicious? Report

Forms