Wise Request For Services Screening

Do you have critical or urgent needs in any of the following:*

Medical IssuesFoodUtilitiesHousingMedical Insurance
Are you 60 years old or older?*

YesNo

Do you have family and/or friends who you can rely on support?*

YesNo
Any additional information:
Do you have any concerns about your housing or home safety?*

YesNo
Any additional information:
Do you feel like your health needs are being addressed?*

YesNo
Any additional information?
Do you have difficulty remembering or concentrating on day to day activities?*

YesNo
Any Additional Information

During the last two weeks have you been bothered by feeling down, sad, hopeless?*

None at allSeveral daysMore than half the daysNearly everyday

During the past two weeks have you been bothered by having little interest or pleasure in doing things?*

None of the daysSeveral DaysMore than half the daysNearly everyday

Please be aware that we do not have 24 hour coverage. We will get back to you as soon as possible. If you have emergent mental health needs please call 911 or the National Suicide Hotline at 1-800-273-8255

Is there anything else you would like us to know about your situation?

Should be Empty: