Nourish Rx Information Request Form

1

Your Name* This field is required.

First Name

Last Name

2

If applying on behalf of someone else, what is their name?

First Name

Last Name

3

What is your birthdate? Or, what is the birthdate of the person you are applying on behalf of?

Date

4

E-mail

example@example.com

5

Phone Number* This field is required.

Area Code

Phone Number

6

Can this phone number receive text messages?* This field is required.

YESNO

7

Do you consent to receive text messages from the Nourish Rx team?* This field is required.

YESNO

8

Has your eating patterns or amount of food intake been disrupted due to food insecurity?

YESNO

9

Because of not having enough food or money for food, have you had to eat lower-quality food or fewer kinds of food?

YESNO

10

Do you or the person you are applying for have Medicaid (WA Apple Health)?* This field is required.

YESNO

11

Do you or the person you are applying for receive medical care at Community Health of Central Washington (CHCW)?* This field is required.

YESNO

13

If you would like to share more about your health condition, you may do so here.

14

Do you have way to get to your NourishRx appointments?

Yes

Sometimes

No

15

Are you willing to stay in touch with the NourishRx team about food boz pick-ups and learning opportunities?* This field is required.

YESNO