S19 - SD Survey

NNMFHC is dedicated to improving the lives of our patients. We also know that this improvement frequently goes beyond the clinical assistance a person can receive in a medical, dental, or pharmaceutical facility. Please know that anything indicated on this survey will be kept in the strictest of confidence by our staff. You will be contacted by a Peer Recovery Specialist at a later date to help you connect with your needs.

Name*

First NameLast Name

Phone #*

Today's Date*

Date

Chart #/ID*

If you are a dental patient, enter the first three letters of your last name. If unknown, enter "NA"

What department(s) do you currently use/plan to use?*

MedicalDentalPharmacyBehavioral Health

Can we support you and/or your family in accessing any of the following? Check all that apply.*

	Yes	No	Not Sure Right Now
Housing and Income
Food
Employment
Utilities
Transportation
Peer Recovery Support (for Substance Abuse)
NA Meetings
AA Meetings
SUD Classes
Mental Health
Personal Safety
Legal Help
Emotional/Spiritual Support
Accessing Medicare/Medicaid
Child/Adult Care and Resources
Medication

If there is any support you may need outside of the above list, let us know and we can help you get connected to resources.