Community health worker
Neigborhood Wellness Center Site Name
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First time visit our Community Health Worker Services
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First time visit our Community Health Worker Services
Client Hispanic Ethnicity
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Living Situation (Can you Describe your current living situation?)
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Where you currently live, do you have any of the following issues? (Indicate all that apply)
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Where you currently live, do you have any of the following issues? (Indicate all that apply)
Some people have made the following statements about their food situation. Please answer whether the statements were OFTEN, SOMETIMES, or NEVER the case for you and your family at any time during the last 12 months. In the past 12 months, you worried that your food would run out before you were able to get enough money to buy more.
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Some people have made the following statements about their food situation. Please answer whether the statements were OFTEN, SOMETIMES, or NEVER the case for you and your family at any time during the last 12 months. In the past 12 months, you worried that your food would run out before you were able to get enough money to buy more.
In the Past 12 months, the food you bought did not last long enough and you did not have money to buy more
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In the Past 12 months, the food you bought did not last long enough and you did not have money to buy more
Transportation: In the past 12 months, has lack of reliable transportation kept you from doing important things like attending medical appointments or meetings, travelling to or from work, getting things you needed for daily living?
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Transportation: In the past 12 months, has lack of reliable transportation kept you from doing important things like attending medical appointments or meetings, travelling to or from work, getting things you needed for daily living?
Utilities: In the past 12 months, have any electric, gas, oil, or water companies threatened to shut off their services to your home
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Utilities: In the past 12 months, have any electric, gas, oil, or water companies threatened to shut off their services to your home
Employment: Do you want help finding a job or keeping your current one
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Employment: Do you want help finding a job or keeping your current one
Family and Community Support: Do you need help finding assistance for any day-to-day living activities such as bathing, preparing, meals, shopping, managing finances, etc.? Do you get the help you need?
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Family and Community Support: Do you need help finding assistance for any day-to-day living activities such as bathing, preparing, meals, shopping, managing finances, etc.? Do you get the help you need?
Mental Health: How often do you feel lonely or isolated from the people around you?
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Mental Health: How often do you feel lonely or isolated from the people around you?
Over the past 2 weeks, how often have you experienced the following feelings? Little interest or pleasure in doing things?
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Over the past 2 weeks, how often have you experienced the following feelings? Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
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Feeling down, depressed, or hopeless?
Do you have a regular family Doctor?
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Do you have a regular family Doctor?
Health Insurance Coverage
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Do you have additional life challenges that we haven't discussed today? If there are none, please enter N/A
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One service we regularly provide is information and resources to help people learn more about things like healthy living and avoiding illnesses and diseases. Would you like to have health education information about any of the following topics?
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One service we regularly provide is information and resources to help people learn more about things like healthy living and avoiding illnesses and diseases. Would you like to have health education information about any of the following topics?
A service we offer is providing people with referrals to social services that are available to assist them with overcoming life conditions that may be impacting their health or could impact there health in the future. Would you like me to provide you with referrals to organizations or resources that can assist you with any of the following life challenges you might be facing?
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A service we offer is providing people with referrals to social services that are available to assist them with overcoming life conditions that may be impacting their health or could impact there health in the future. Would you like me to provide you with referrals to organizations or resources that can assist you with any of the following life challenges you might be facing?
Would you be willing to have me contact you after this consultation to see if I can be of any further assistance and to find out if you've been able to successfully access and take advantage of the referrals I've given you
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Would you be willing to have me contact you after this consultation to see if I can be of any further assistance and to find out if you've been able to successfully access and take advantage of the referrals I've given you
Would you like to set a follow up on the things we discussed?
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Would you like to set a follow up on the things we discussed?
How soon would you like me to contact you to follow up?
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How soon would you like me to contact you to follow up?
CHW ONLY: If you provided health insurances assistance, please indicate the type of health insurance you assisted with
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CHW ONLY: If you provided health insurances assistance, please indicate the type of health insurance you assisted with
CHW ONLY: If you assisted with a health insurance application, please indicate the status of that application
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CHW ONLY: If you assisted with a health insurance application, please indicate the status of that application
CHW ONLY: This is social service referrals. If you able to meet the needs of the client at this initial consultation, please indicate what needs were met
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CHW ONLY: This is social service referrals. If you able to meet the needs of the client at this initial consultation, please indicate what needs were met
End of visit summary For CHW Only: Provide a summary of the initial consultation, include strategies or techniques that helped facilitate a successful client consultation, lessons learned while helping this client, and any challenges you encountered while helping the client.
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