In a Pinch?
This form is HIPAA protected, and is only shared with SALT Outreach staff related to this program. AdventHealth will NOT be notified or know that you have completed this assessment unless you provide SALT express signed permission. Completing this form helps us to determine your eligibility for this program. A SALT Case Manager will be in touch with you within the next business day. ***This is a pilot program only serving AdventHealth Orlando, Winter Park, Winter Garden, Apopka, and Altamonte Springs***
AdventHealth Employee Information
Full Name
*
First Name
Last Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How Did You Hear About This Program?
*
Chaplin
Human Resources
Supervisor
General Email
Paper Flyer
Employee Assistance Portal
From a Work Colleague/Co-Worker
Other
How Did You Hear About this Program?
*
Preferred Contact Methods (Select all that apply).
*
Phone Call
Text Message
Email
Other
What Time of Day is it Best to Contact You?
*
Please Select
Morning
Afternoon
Evening
Anytime
Job Title
*
Department
*
Your Work Location
*
AdventHealth Altamonte
AdventHealth Apopka
AdventHealth Winter Park
AdventHealth Winter Garden
AdventHealth Orlando
Other
If you chose 'Other,' Please write which AdventHealth you work at:
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Reason for Inquiry
What is Your Current Housing Status?
*
Pending Eviction within 14 Days
Currently Experiencing Homelessness
Housed & No Pending Eviction
Staying at a Friends House
Staying with Family
Other
Have You Received Help from the AdventHealth Hope Fund Within the Past 3 Years?
Yes
No
I Don't Remember
Would You Be Open to a Housing Situation Where You Room with Another AdventHealth Employee from the Same Hospital You Work at? (This helps us look at options that involve two incomes)
Yes
No
Maybe
Would You Be Open to a Housing Situation Where You Room with Another AdventHealth Employee from a Different AdventHealth Hospital? (This helps us look at options that involve two incomes)
Yes
No
Maybe
Would You Be Open to Renting a Room to Save Money?
Yes
No
Maybe
Please Share More About Your Current Situation and What Your Current Needs Are.
*
Optional Release of Information
All information provided in this assessment is confidential and only shared with SALT Team Members who will be involved in your care. However, if you would like us to include a specific AdventHealth Chaplain, please specify and sign below, and we will do so at your request.
Would you like an AdventHealth Chaplain Involved in Your Care with SALT?
*
Yes
No
Please Share the Full Name of the Chaplain You Would Like us to Speak With.
Below for Internal Use Only
Skip this section if you are an AdventHealth Employee
Who Completed This Call?
Please Select
Isai
Eric
Gina
Kyra
Devon
Denise
Yael
Renae
Jasmyn
Jocelyn
SALT Team Member Notes
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