URWell(NC) Holistic Health Screener
We believe that everyone should have the opportunity to be holistically healthy. Not having enough food, reliable transportation, or a safe place to live can make it hard to be healthy. Please answer the following questions to help us better understand you and your current situation, it should only take about 5 minutes to complete. We may not be able to locate resources to meet all of your needs, but we will try to help as much as we possibly can. Thank you in advance for taking the first step to become "shackle free".
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What is your name? (last, first, middle) *
What is your date of birth? *
What is your residential address?
What is your mailing address?
What is the best contact number for you?
What is your email address?
What is the best method of contact? *
What county do you reside in? *
Are you registered to vote?
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SF's utilizes the assistance of beauty & barber shops to help spread the word in rural communities. Who is your barber, beautician, nail tech, or tattoo artist? If none, enter n/a here.
What is your beauty professional's phone number, email address, or website? *
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