Community Health & Resource Network Screening Form
Local organizations and healthcare providers working together to connect people to the resources they need.
The information collected in this form will be used to determine eligibility for resources, help you access them, and coordinate services between network partners to better serve you.
When organizations can share information, they can more quickly and easily connect you to care. Submitting this form will not change your ability to receive medical services, treatment, or social services
Preferred Language
Send this form to yourself or someone else
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Send
In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?
Select all that apply.
*
Childcare
Education
Employment
Food
Healthcare Access
Housing / Utilities
Interpersonal Safety
Legal Services
Social Support
Transportation
Other
Early Childhood Support
Do problems getting childcare make it difficult for you to work or study?
Yes
Education
Do you want help accessing educational or training programs?
Yes
Employment
Do you want help finding or keeping work or a job?
Yes
Food Security
Recently, did you eat less than you felt you should because there wasn’t enough money for food?
Yes
Do you have trouble with physically shopping, cooking, and/or feeding yourself?
Yes
Healthcare Access
Recently, was there a time when you needed to see a doctor or get medications but could not because of cost?
Yes
Housing / Utilities
What is your living situation today?
I have a steady place to live
I have a place to live today, but I am worried about losing it in the future
I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside, or in a car)
Think about the place you live. Do you have problems with any of the following? Choose all that apply.
Pests such as bugs, ants, or mice
Mold
Lead paint or pipes
Lack of Heat
Oven or stove not working
Smoke detectors missing or not working
Water Leaks
None of the above
Recently, has the electric, gas, oil, or water company threatened to shut off services in your home?
Yes
Already shut off
Interpersonal Safety
You deserve support. Please remember the Network is not a crisis service. Call the 24-Hour Hotline at 607-277-5000 or 911 for an emergency.
Do you feel physically and emotionally safe?
No
Social Support
Do you feel lonely or isolated from those around you?
Yes
Transportation
Recently, has lack of transportation kept you from medical appointments, meetings, work, or getting things for daily living? Check all that apply.
Yes, it has kept me from medical appointments or getting medications
Yes, it has kept me from meetings, appointments, work, or getting things that I need
If you checked yes to any of these boxes, would you like to be contacted by a navigator to connect you with available resources in our community?
*
Yes
I do not want to be contacted directly: to get help from a live person, reach out to 211 Tompkins Cortland by dialing 877-211-8667.
Are any of your needs urgent? For example: I don't have a place to sleep tonight.
*
Yes
No
Tell us a little bit more about yourself
I am submitting this screening for myself
I am a caretaker (submitting on behalf of a spouse, parent, guardian, other friend/ family member)
I am a Community Based Organization staff member (submitting on behalf of client)
Name
*
First Name
Last Name
Zip Code
Birth Date
-
Month
-
Day
Year
Date
Name of individual for whom you are submitting this form
First Name
Last Name
Relationship to individual
Preferred Method of Contact
*
Phone (text me)
Phone (call me)
Email
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Organization Name
*
Any additional information to share with the navigator?
Submit
Should be Empty: