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Date
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Legal Name
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Legal Address
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Primary email address?
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Are you legally Married
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Do you have State insurance
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New Yes / No
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Case Manager Name
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Case Manager NPI #
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Is American English your first language?
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Do you have a Primary Care Physican
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Who is your Primary Care Physician
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Have you have blood work done recently
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Have you had a yearly physical
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Where is your Pirmary Care Physicians Office
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What is your Primary Car Physician's Office number
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May your CM contact your PCP
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Any other Medical Providers
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Other Medical Providers information
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Do you have a Dentist
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What is your Dentist Name?
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Denist Phone Number
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Dentist Business Address
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Last Dental Visit?
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What are your immediate dental needs
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Do you use Donated Dental
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Do you use Dental Connections
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Do you have a Counselor?
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Are you interested Positive Psychology
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Have you had your hearing tested within the last 2 yrs
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When was your last eye exam?
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Do you use street drugs?
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Are the use of street drug a problem
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Do you need detox?
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Do you take Dr. preseribed perscriptions
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Do you take perscriptions as perscribed
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Do you have prescription drug coverage?
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Are you legally working?
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Have you ever legally worked before
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Do you need help finding employment
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How many years have you legally worked?
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Have you filed for unemployment, if so, when?
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Have you applied for Social Security
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Do you have a rep payee
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Do you have any financial needs or burdens such as debt or outstanding utility bills
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Do you have a legal residence where you stay year round and recieve mail?
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Do you lease or rent a room?
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Do you lease or rent an apartment
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Have you filed for section 8 housing
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Are you facing any evictions
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Are you able to pay rent on time every month?
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If nunable to pay rent on time, why?
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Do you have any pending legal cases currently?
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Do you have any pasted unsealed involment with the legal system?
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Do you have a pubilc or private legally barred attorney?
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Do you have a legal guardian?
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Do you have a Durable Power of Attorney for Healthcare?
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Do you want The Case Manager Kaitlyn R Reed to be your Durrable Power of Attorney for Healthcare
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Do you currently hold a valid NH State Drivers License
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Do you currently haveyour own form of reliable transportation? i.e car, van or truck
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If unable to hold a valid Drivers License are you able to afford safe local transportation? i.e bus, uber or lyft?
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Does your unmet transportaion needs interfere with work, going to the doctor or grocery store?
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Did you graduate from High School?
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If so what year?
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Have you completed any college?
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If so what year(s)?
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If not, would you like to attain a higher degree of education??
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Are your current educational goals being met?
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Do you currently volunteer?
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Would you rather learn a trade? Electrician, black smith or carpenter?
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Are you currently on Medicaid for Employed Adults with Disabilities?
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Do you have a local library card?
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New Short Text Field
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How do you structure your free time? adult recreational leauges, gym or AA?
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Is spirituality important to you?
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Do you participate in activies related to spirituality?
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Are your spritual needs being met
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If not where can they improve?
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Do you have young children?
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Do you have sole custody of your children?
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If not, what type of custody do you share with the other parent?
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Do you require supervised visits with your children?
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Are you current childcare arrangments being met?
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How would you rate your social supports currently?
• • •
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What are your goals related to creating and maintaing postive social supports?
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Do you need legal asistance reducing or removing negative peer influence?
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