CLIENT INFORMATION

Notes:  Who is this form for?  Women age 35-64 who are uninsured, under-insured and/or do not qualify for EWM. 
*Please complete assessment form and submit.

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* 1. Date Completed this form with client:

Date

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* 2. Venue Name:

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* 3. Assessment Completed:

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* 4. Name of Community Health Hub? 

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* 5. Client ID#: (Clients first 3 letters of last name and date of birth mmddyy; example:  CRA020564)

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* 6. Birthdate:

Date

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* 7. Mailing Address:

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* 8. Contact Information:

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* 9. Preferred way of Contact?

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* 10. Is it okay to text your cell phone?

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* 11. Are you of Hispanic/Latina(o) origin?

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* 12. What is your primary language spoken in your home?

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* 13. What race or ethnicity are you? (check all boxes that apply)

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* 14. If American Indian/Alaska Native, what Tribe?

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* 15. Are you a Refugee?

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* 16. Highest level of education completed:

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* 17. If yes, where from?

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* 18. County of residence in Nebraska:

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* 19. Do you have a primary care physician?

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* 20. Do you have Health Insurance?

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