Health Related Social Needs

Sharon 2.0

AI Analzyze
Examples: I need help finding housing, I need help feeding my children, I don't feel well. I need help.
Can Sisters In Common (we) share your name, phone number, address, and email to get you the help and services, you are asking for?
Contact Number Type
Is it ok to leave a detailed message at this number?
If Address is not available, enter 'NA' in Address Line 1 and enter County currently residing. If Client is experiencing homelessness, enter 'Homeless' in Address Line 1 and enter County currently residing.
Address
Address
City
State/Province
Zip/Postal
Country
Have you (if self-referral) or the individual you are referring been impacted by the COVID-19 pandemic?
Gender
Race
Ethnicity
Primary Language Spoken
Social and Health Barriers. Do you (if self-referral) or the individual you are referring have any concerns with the following social barriers? (select all that apply)
Do you (if self-referral) or the individual you are referring have any concerns with the following health barriers? (select all that apply)
CHW or Person asking questions
If you DO NOT see your name listed select other and put it in
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