Apply for Gaja Health

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Please fill out the below questions to apply and a Health Advocate will call or text if you are eligible.

**Completing this form marks your agreement to the Gaja Health Privacy policy and Terms of use:

- Privacy Policy: https://gogajahealth.com/app/help/privacy-policy.html
- Terms of Use: https://gogajahealth.com/app/help/terms-of-use.html

First name *

Last name *

Email address *

(We promise to keep your email private)

Mobile phone number *

For example: 555-333-444 - (we promise to keep your phone number private)

Zip code *

(Currently, Gaja Health requires participants be residents of an Alameda county zip code)

Do you have Medi-Cal insurance? *

To use Gaja Health, you must be enrolled in or eligible for Medi-Cal. Not sure if you are eligible? Click here to check the guidelines: https://www.dhcs.ca.gov/services/medi-cal/Pages/DoYouQualifyForMedi-Cal.aspx

Yes

I am not enrolled in Medi-Cal, but think I am eligible

What would you like help with? *

Select all that apply

Food (SNAP, CalFresh, Foodstamps)

Food market/pantry

Housing Resource Referrals (Shelters/Deposit Assistance/Housing Listings)

Medi-Cal renewal

Transportation

Utility/Energy Assistance

Applying for financial benefits (WIC, SSI, SNAP, General assistance, etc.)

Medical care, medicine, medical supplies

Mental health services (reducing stress, etc.)

Employment Resources

Childcare

Maternal support

Family/Parenting Resources

Dental services

Vision services

Access AT&T

I don't need help with any of these

Other:

Required

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This form was created inside of Gaja Health.