Request for Services

Request for Services

Please fill out the form below if you are interested in no-cost services provided by The Wellness Coalition. All information collected is confidential. If you would like to speak to someone on the phone, please call 334-293-6502.
Name*

First NameLast Name
Date of Birth

MonthDayYear
Gender*

MaleFemalePrefer not to say
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*

Area CodePhone Number
Alternative Phone Number (if available)

Area CodePhone Number
Email Address (if available)
Example: johndoe@gmail.com
What type of health insurance do you have?*

NoneMedicaidMedicarePrivateOther
What type of chronic disease(s) do you have? (select all that apply)*

High Blood PressureDiabetesObesityCancerChronic Obstructive Pulmonary Disease (COPD)ArthritisMental Condition (Depression, Schizophrenia, Bipolar, etc.)AsthmaOtherNone
What services are you interested in?*

Help finding a health care providerHelp with application(s) for free medicationHelp with health insurance enrollmentClasses on benefits and use of health insuranceHelp to set and reach wellness goals for chronic disease(s)Diabetes Self-Management Program (DSMP) ClassesChronic Disease Self-Management Program Classes (Living Well)General health and wellness informationDiabetes Prevention Program (DPP) ClassesHeart health workshops and supportLactation Support Services through the Baby CaféOther
How did you hear about The Wellness Coalition?*

From another agency/organizationAds on TV or some other placeAn online searchA friend/family member/word of mouthOther
If another agency/organization referred you, please tell us the name of the agency.
Please provide additional information that will help us better assist you.
PLEASE CONTACT ME ABOUT SERVICES PROVIDED BY THE WELLNESS COALITION. I UNDERSTAND THAT THERE IS NO OBLIGATION TO USE THESE SERVICES AND THAT THERE IS NO COST FOR THESE SERVICES.*

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