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Thank you for completing this form. This will help us to assess how we can map our your support and resources. Please be honest. Completely answer the questions. This should take you approx 10 minutes.
Prefer not to say
$0 - $25,000
$50,000 - up
Some high school
Trade school (mechanic, beauty school, etc)
Stable - No concerns about housing
Unstable - At risk for eviction, trouble paying rent month to month
Homeless - You do not have a place of your own, live with family (temporarily), or in a shelter
Tell us about your physical health. Check the items you need help with.
improve your physical activity
learn how to cook healthy foods
Tell us about your emotional health. Check the items you need help with.
Resources to support groups
Referral to a mental health provider
Learn how to take care of my mental health at home
What are your top 3 goals? Make sure they are smart, measurable, attainable, reasonable, and timely. (Example: I'd like to lose 3lbs in 6 weeks by improving my eating habits)
Thank you for completing this assessment!
You will be contacted to set up a time to talk about your goals!
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