• MHCI Participant Enrollment & Needs Assessment Form

    Metamorphosis Community Project, Inc. | Contract BPM055359

  • Section A — Participant Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Section B — Household Information

  • Housing Status / Estado de la vivienda*

  • Section C — Demographics

  • Employment Status / Estado de empleo*
  • Worked for or was a contractor for the federal government and was laid off or saw hours cut? / Trabajó o due contrastista del gobierno federal y fee desperado o via reducidas sus hora de trabajo?*
  • Received government benefits and lost access to or saw reduction in monthly assistances? ' Recibió beneficios del gobierrno y perdió el access a la asistencia sensual o via una reducciión en ella?*
  • Have you been impacted by increases in the price of basic necessities (i.e., groceries, rent, medicine)? / Seha vista afectado for augments en el precious de las necesidades básicas (es decor, comestibles, alquiler, medicines)?*
  • Within the last 30 days, how often did your household worry that food would run out before you had money to by more? / En los últimos 30 días, ¿con qué frecuencia su hogar se preocupó de que se acabaría la comida antes de tener dinero para comprar más?
  • Annual Household Income / Ingresos Anuales del Hogar*
  • Health Insurance Status / Estado del seguro de salud*
  • Do you have a primary care provider that you see for routine healthcare
  • Would you like assistance connecting to a primary care provider? / ¿Le gustaría recibir ayuda para conectarse con un proveedor de atención primaria?*
  • Which healthy lifestyle activities would you be interested in participating in? (Select all that apply.) / ¿En qué actividades de estilo de vida saludable estarías interesado en participar? (Selecciona todas las que apliquen.)*

  • Section D — Program Interest

  • Other Metamorphosis Resources / Otros recursos sobre la metamorfosis*
  • Have you or anyone in your household experienced need in the following areas within the past 12 months? / ¿Ha experimentado usted o alguien en su hogar alguna necesidad en las siguientes áreas durante los últimos 12 meses?
  • How did you hear about MHCI?

  • Section E — Consent

  • Consent
  • If participant prefers not to sign: Verbal consent documented by staff?
  • Have you downloaded our app? /*
  • Consent Date*
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  • Should be Empty: