COLUMBIA COUNTY VOLUNTEERS IN MEDICINE CLINIC       SOCIAL SERVICES ASSESSMENT FORM
310 EAST THIRD STREET    P.O. BOX N                                                             SHEET 4                 
MIFFLINVILLE, PA  18631
570-752-1780 or 570-752-1786 FAX

PLEASE COMPLETE THE FOLLOWING TO ASSIST CCVIM CLINIC SOCIAL SERVICES – CIRCLE ALL THAT APPLY.

1. Would you like information on any of these insurance/benefits you may be eligible for?

 CHIP (Children’s Health Insurance Plan)     Adult Basic     Medical Assistance     Veteran’s Benefits     Medicare

2. Do you need help applying for any of these insurance benefits?

 CHIP (Children’s Health Insurance Plan)     Adult Basic     Medical Assistance     Veteran’s Benefits     Medicare

3. Do you need any of the following?

 Food     Heat (Please specify type of heat.)  _____________________________ Housing    Clothing     Electric   

4.  Do you feel safe in your relationships?                                           Yes         No

5.  Do you need help finding a job or learning job skills?                    Yes         No

6. Are you interested in any of these?

Classes for English as a second language                                                 Vocational rehabilitation      
Classes for a generally equivalency diploma (GED)  

7. Do you need help applying for any of these income benefits?

Social Security             Supplemental Social Security (SSI)    Social Security Disability Income (SSDI)
Public Assistance                          Child Support                                 Unemployment compensation

8. Do you have a drug or alcohol problem?                                           Yes     No

9.   Would you like to discuss a drug or alcohol concern you have about yourself or someone else?    Yes   No

10.  Have you ever received counseling or psychiatric treatment?      Yes    No

11.  Would you like more information on mental health resources in the area?     Yes      No