YWCA Health Access Intake Form

Thank you for reaching out! This form is HIPAA-Protected so your information is kept private and confidential. Please share what you would like us to know to better assist you. The next available Community Health Worker with reach out to you within 2-3 business days, oftentimes sooner.

Referral Date

Enter today's date

Preferred Name

Type First and Last name we should use

Legal Name

Type below if different than Preferred Name

Are Language Services needed?

Best way to contact

Phone? Email? Text?

Phone Number

Phone

Email Address

Best Time to Call

How can we help?

Select as many as needed. (Scroll down to see all options)

Birthdate

Last four digits of SSN

Enter 0 if do not have SSN

What is your housing status?

Zip Code

Where you slept last night

Do you have any disabling conditions? Physical/Mental/Emotional

Any ongoing health conditions?

Are you a Veteran?

Have you ever experienced domestic violence?

What is your household size?

How many children under the age of 18?

What is your yearly income level?

Very Low = $0 - $24,300
Low = $24,301 - 40,500
Moderate = $40,501 - $63,500
Above Moderate = $63,501+

Pronouns

Please type below if your pronoun is not listed

Sex Assigned at Birth

*This is only needed for preventative care coverage and/or scheduling preventative care appointments*

Would you like to share your Ethnicity?

Would you like to share your Racial Identity?

Select as many as needed

Anything else you'd like us to know?

Please include any appointment preferences if applicable (ex: AM/PM, gender, days NOT good for an appointment, etc.)

Do you have medical insurance?

Do you need transportation assistance to/from your appointment?

Please check box if Yes

Referring Source

How'd you hear about us? (e.g.: Website, organization, case manager/advocate, nurse, etc.)

Send me a copy of my responses

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