POST APPOINTMENT INTERVIEW

Name

First NameLast Name
Interview Date

MonthDayYear
Date
We're calling back to see how your appointment went, and make sure you feel capable of getting more care if you need it. Also if you know of any other people who need help with these issues please have them call or Whatsapp me.
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Appointment

MonthDayYear
Date
Did we schedule transportation for you to this appointment?

YesNo
What was your need for the appointment?
How did it go?
Who did you meet with?
Do you need additional appointments to be made?
Did you receive any medications at the appointment?
Do you need referrals to any other services?
Do you feel like you know how to get another appointment on your own? What number would you call?
If no, what information would help you feel comfortable?
Demographics
Age
Country of Origin
Spoken Language(s)
Education Level
English Proficiency

1

2

3

4

5

1 is Low, 5 is High
Are you in English classes?
Family Size
Are you married?

YesNo
Income Level (Household 1 = $14,580, Household 2 = $19,720, Household 3 = $24,860, Household 4 = $30,000)

Below Federal Poverty LineAt Poverty LineAbove Poverty LineNo IncomeUnsureOther
Zip Code
Do you have access to transportation?

I have access to a bus routeI have a carI do not have access to transportationOther
Notes
Should be Empty:

Demographics