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Malama User Id
Malama App User ID
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Which health insurance do you have?
*
Please Select
Santa Clara Family Health Plan
Anthem Blue Cross
Kaiser Permanente
San Francisco Health Plan
Health Plan of San Mateo
Partnership Health Plan of California
Other
I'm not sure
If you're not sure, select "I'm not sure"
Are you currently enrolled in Medi-Cal (Medicaid in California)?
*
Yes
No
Not sure
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Which race/ethnicities do you identify with? (Select as many as you'd like)
*
Black/African American
Alaskan/Native American
Native Hawaiian/Pacific Islander
Hispanic/Latinx
Filipino
Chinese
Vietnamese
White/Caucasian
Other
Which services are you interested in? (Check as many as you'd like)
*
Free meals
Housing assistance
Transportation options
Doula services
Finding a doctor
Other
Do you need help applying for Medi-Cal?
Yes
No
Other
Are you currently experiencing any of the following?
I'm pregnant or postpartum (12 months since last birth/termination/loss)
I don't have housing/ at risk of homelessness
I've been/am using drugs
I have mental health concerns
I was recently jailed or in a correctional facility
I have an intellectual/developmental disability
None of the above
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Are you experiencing any challenges in your current living situation?
Yes
No
Other
Please describe your situation:
How many times have you visited the emergency room (ER) in the past 12 months?
visits to the ER in the past 12 months
What's your name?
First Name
Last Name
When is your birthday?
-
Month
-
Day
Year
Date
Which do you prefer?
Phone
Text
Email
In-person
What's the best phone number?
Please enter a valid phone number.
When would you like us to reach out?
e.g., mornings/evenings, weekends, Tuesday afternoons
What's your email?
example@example.com
Email
example@example.com
Phone Number
Please enter a valid phone number.
How did you hear about Malama?
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