PLEASE REVIEW AND COMPLETE:

In order for us to evaluate your need, you MUST complete this General Intake Form.

For questions and concerns please contact Dannielle Castro at 518-664-8322 ext 1010 or Andrea Cowell at 518-664-8322 ext 1003

General Intake Form

Please complete if you are in need of services from MACSC

Step 1 of 5

Sharing of Information

Be sure to read the below in it's entirety.

Consent(Required)

I have read and understand the following:

By signing this form, I understand that I am allowing the Mechanicville Area Community Services Center (MACSC) to use or share all of my information with affiliated organizations in order to receive available services within MACSC.

I may revoke this authorization at any time by notifying the Mechanicville Area Community Services Center in writing at the address above, but, if I do, it will not have any effect on actions that MACSC took before receiving the revocation.

I understand that this authorization is voluntary. I understand that my records are protected under Federal Confidentiality Regulations and cannot be shared without my written consent unless otherwise provided for in the regulations.

I have read and understand the nature of this agreement. This authorization will expire one year from the date of signature.

Client Name(Required)

First Last

Date(Required)

Parent/Guardian

First Last

(if required)

Date

Golf Fundraiser

This Event has past and currently Registration CLOSED.
Our Next Tee Off Against Domestic Violence Golf Fundraiser will be at Mechanicville Golf Club June 2026. More Details to follow.

PLEASE REVIEW AND COMPLETE:

In order to reserve MACSC facility this Facility Use Request Form MUST be completed.

For questions and concerns please contact Emma Oest

Facility Request Form

General Information

Email

Enter Email Confirm Email

Name of Group/Person:(Required)

Organization:

Contact Person:(Required)

First Last

Phone(Required)

Address(Required)

Street Address City State ZIP Code

Program Name/Type:

Requested Date(Required)

Start Time:(Required)

:

End Time:(Required)

:

Requested Date

Start Time:

:

End Time:

:

Requested Date

Start Time:

:

End Time:

:

Note:

This section is for additional information you would like to provide to MACSC

Is the program open to the public?(Required)

Yes

No

Does your program require advanced registration?(Required)

Yes

No

Are there fees associated with your program?(Required)

Yes

No

Facility Rental Agreement

Consent(Required)

I agree to MACSC Facility Rental Agreement

WHEREAS, (Group/Person) wishes to use the facility of the Mechanicville Area Community Services Center, for use states in “Revocable License”; and WHEREAS, the Mechanicville Area Community Services Center agrees to allow such use.

NOW, THEREFORE, in consideration of the rental fee paid by the User, the parties hereto agree as follows:

The User must provide written proof (a certificate of liability insurance), of liability insurance of limits not less than One Million Dollars ($1,000,000.00) per occurrence written by a company licensed to do business in New York State, and acceptable to the Mechanicville Area Community Services Center and City of Mechanicville.

As consideration for participation in facility use sponsored by the Mechanicville Area Community Services Center and/or using equipment of said Association, each participant agrees to assume all liability for injury and/or damage resulting from such participation. Participants further agree to hold Mechanicville Area Community Services Center and the City of Mechanicville free and harmless of any act of omission or commission or negligence on the part of said association or their officers, agents or volunteers.

I have read, understand and agree to the MACSC Building Checklist and have met the above criteria. I understand my rate for building usage of half-payment is due a week before the event begins, and my rate for building usage of balance of payment/ Full Payment is due one day before the event. I also understand that my security deposit will be returned following my event as long as the space is left as it was found and my FOB is returned.

Name(Required)

First Last

Date(Required)

Facility Rental Guidelines

Consent(Required)

I agree to MACSC Facility Rental Guidelines

All surface areas in rental rooms must be clean of debris and wiped down if applicable.

All floors in rental rooms must be swept clean of debris and washed if applicable. This includes the kitchen area, tables and chairs. Tables and chairs should be neatly stacked and returned to their locations.

Garbage must be removed from all rental rooms and placed in the outdoor garbage receptacle & recycling.

Please respect MACSC space. If you have signed up to use a particular part of the building, please be sure to keep your guests, children and colleagues in that part of the building. This is to ensure safety for all.

As the responsible individual for the rental party as outlined in the FACILITY REQUEST FORM and THE FACILITY RENTAL AGREEMENT, I have read and understand the following conditions of rental for the Mechanicville Area Community Services Center facility and/or grounds.

Name(Required)

First Last

Date(Required)

Anything That Floats

This Event has past and currently Registration CLOSED.
Our Next Anything That Floats event will be April 2026. More Details to follow.

EVENT CLOSED

This Event has past and currently Registration CLOSED.
Look out for more fun and exciting events like this in the future. To learn more about all the events we offer at MACSC, contact Community Engagement Director info@macscinc.org (518) 664-8322

PLEASE REVIEW AND COMPLETE

In order for us to provide your child with a winter coat, this sign-up form MUST be completed and submitted with all required documentation.

Important Reminders:

If you have completed the School Supply Assistance Request form and have requested a Winter Coat on that form, DO NOT complete this form.
MACSC’s Winter Coat program operates on a first-come, first-serve basis, nothing is guaranteed, and application priority will be given to families currently participating in MACSC programming.

Requirement + Documentation: Please review and submit the required documentation below with your application. Applications WILL NOT be accepted without a required documentation for each child.

Proof of Residency – MUST live in the following school districts: Mechanicville, Stillwater, Hoosick Valley & Waterford.
Proof of Guardianship – MUST be submitted for each child (e.g. – Custody Agreement, Birth Certificate)
Photo Identification – MUST provide a valid Photo ID (e.g. – Driver’s License, Non-Driver ID, Passport)
- NOTE: Photo Identification will be required to submit application and to pick-up items.
Specific Coat Wishlist– You MUST submit size, color (e.g. – Youth Small, Pink)

If you have any questions about the Winter Coat Sign-up or Required Documents, contact Dannielle Castro at 518-664-8322 ext 1010 or Andrea Cowell at 518-664-8322 ext 1003

Event Payment & Refund Policy

Payment & Refund Policy

Name: Christmas Day ~ MACSC CLOSED
Start: 2025-12-24T00:00:00-05:00
End: 2025-12-26T23:59:59-05:00
Location: Mechanicville Area Community Services Center (MACSC)

Payments: In order to ensure your reservation for any of our fundraising Events or Bus Trips, payment MUST be made in full at the time of registration. If you have not made a payment, your reservation WILL NOT be guaranteed. Any outstanding payments MUST be made within 3 weeks of Event or Bus Departure.

Pay Online: Credit Card payments can be processed at the time of registration.
Pay in Person: Cash/Checks should be paid in person at MACSC to Community Engagement Director
Pay via Mail: Checks should be made payable to MACSC, 6 South Main St, Mechanicville NY 12118

Refunds: In the event of an emergency or last-minute cancellation, please contact our office at info@macscinc.org (518) 664-8322. All cancellations within 15 days of Event or Bus Departure are non-refundable.

Community Hearts

This Event is currently CLOSED.
Our next Community Hearts Event will be May 2023. More Details to follow.

For more information contact us at info@macscinc.org 518.664.8322

REGISTRATION DETAILS:

Effective April 1, 2024
Before/After Care registration

MACSC Site Locations
Mechanicville Elementary School (housed at the MES for its 4th School Year)
The MACSC SACC Before and After care program at Mechanicville Elementary School will be accepting applicants for the 2024-2025 School Year on 06/03 for Current SACC families and 06/10 for NEW families. To register, please complete the SACC Registration.

Hoosic Valley School (PM Care ONLY)
The MACSC SACC After care program at Hoosic Valley School will be accepting applicants for the 2024-2025 School Year on 06/03 for Current SACC families and 06/10 for NEW families, but space is limited. To register, please complete the SACC Registration.

If you have any questions or concerns regarding School Year Program or Registration, please contact
Marianne Sgambati (Child Care Director) 518-664-8322 ext 1009/Program cell 518-335-1739 or Priscilla Izzo (Assistant Director) Program Cell 518-858-5568

PLEASE REVIEW AND COMPLETE

In order for us to provide your child with School Supplies and or a Winter Coat, this sign-up form MUST be completed and submitted with all required documentation.

Important Reminders:

If you have completed the Winter Coat Assistance Request form and have requested a Winter Coat on that form, DO NOT request a winter coat on this form.
MACSC’s School Supply & Winter Coat program operates on a first-come, first-serve basis, nothing is guaranteed, and application priority will be given to families currently participating in MACSC programming.

Requirement + Documentation: Please review and submit the required documentation below with your application. Applications WILL NOT be accepted without a required documentation for each child.

Proof of Residency – MUST live in the following school districts: Mechanicville, Stillwater, Hoosick Valley & Waterford.
Proof of Guardianship – MUST be submitted for each child (e.g. – Custody Agreement, Birth Certificate)
Photo Identification – MUST provide a valid Photo ID (e.g. – Driver’s License, Non-Driver ID, Passport)
- NOTE: Photo Identification will be required to submit application and to pick-up items.
School Supply List – MUST be provided to ensure your child(ren) receives the correct supplies needed for school. If you do not submit a supply list, your child(ren) will receive grade appropriate supplies.
Specific Coat Wishlist– You MUST submit size, color (e.g. – Youth Small, Pink)

If you have any questions about the School Supply and or Winter Coat Sign-up or Required Documents, contact Dannielle Castro at 518-664-8322 ext 1010 or Andrea Cowell at 518-664-8322 ext 1003

EVENT CLOSED

This Event has past and currently Registration CLOSED.
Look out for more fun and exciting events like this in the future. To learn more about Parenting or Family Resource opportunities, contact Family Resource Advocate at (518) 664-8322 ext 1010

PLEASE REVIEW AND COMPLETE

The Arts Center on the Hudson is now accepting inquires for the 2025 Event season.

To Inquire about the event space and availability, complete the Inquiry form below
For questions and concerns please contact Holly LaTorre at (518) 664-8322 ext 1017

Arts Center on the Hudson Facility Inquiry Form

Email(Required)

Enter Email Confirm Email

Name(Required)

First Last

Phone(Required)

Type of Event you would like to book(Required)

Wedding

Exhibition/Trade Show

Party/Celebration

Food and Beverage Event

Convention/Expo

Workshop/Training Session

Art/Craft Fairs

Health and Wellness Event

Other

Event Date(Required)

Event Time(Required)

:

PLEASE REVIEW:

The Arts Center on the Hudson is now accepting bookings for the 2025-26 Event season.

2025-26 Rental Rates
Effective January 1st, 2025

For questions and concerns please contact Holly LaTorre

Non-Wedding Private Event Rental

Lower Level: $300/ 4-hours
Upper Level: $500/ 4-hours

Special Rental Event

Recitals: $150/ 4-hours
Workshops/Training/Classes
- Lower Level: $150/hour
- Upper Level: $200/hour
- Upper & Lower Level: $400/4-hour
- **Monthly rates available**

Wedding Rental

May 15 – September 15
- Ceremony ONLY: $800/ 4-hour
- Reception ONLY: $1,600/ 4-hour
- Ceremony & Reception: $2,100/ Full Day
September 16 – May 14
- Ceremony ONLY: $1,000/ 4-hour
- Reception ONLY: $1,800/ 4-hour
- Ceremony & Reception: $2,300/ Full Day

Proceeds from your support directly benefit the community

Extended Hours, Advance Access & Post-Event Breakdown Fee:
An additional fee applies for events exceeding the initial rental time period, accessing the event space the day prior for setup and/or the day following for breakdown. This option is subject to availability and must be arranged in advance.

Please Note:
The Mechanicville Area Community Services Center, Inc. reserves the right to amend any fee structure and/or agreement based on the organization and facility use requests. Fee structures may be adjusted to reflect in-kind services based upon mutual agreements between the organization and/or its affiliates and the Mechanicville Area Community Services Center, Inc. Organizations may petition the Board to waive building usage fees in exchange for providing an active member for the Center’s Board of Directors. Each Board member may only represent one organization with waived fees.

School Supply Assistance Program is CLOSED

The Mechanicville Area Community Services Center School Supply & Winter Coat Assistance Program is CLOSED. If you have missed the sign-up period and are in need of School Supplies for your child, please contact our Resource Advocate at 518-664-8322 ext 1010. This program will return for 2025-2026 School Year. Sign-Ups for this program will be available early July 2025. Please check back for additional information as it gets closer to Summer 2025.

Tentative School Supply Sign-Up Date: Monday, June 30th, 2025
Tentative School Supply Distribution Date: Thursday, August 28th, 2025, 9am-2pm

For questions and concerns please contact us at 518-664-8322

PLEASE REVIEW: New Annual Income Limits

Effective June 1st, 2024 – May 31st, 2025

NYS Department of Social Services (DSS) can assist low-income families who need child care to become/remain employed. Child care information and referral, Dept. of Social Services subsidized child care (as funds remain available for eligible families).

Eligibility Criteria:
Child Care Block Grant – Child Care for low-income working families at/below 300% poverty level
TA Transitional – Child Care for former TA recipients who are employed at/below 300% poverty level.
Expansion of Child Care Assistance – Child Care for low-income working families at/below 300% poverty level
Workforce Development Institute (WDI) – Saratoga County partners with WDI to provide Child Care to working families at/below 375% poverty level. Click HERE to find out more about the WDI Child Care Scholarship Program.

Income Limits: Effective June 1st, 2024 – May 31st, 2025
Family Size Annual Monthly
1 $ 56,488.48 $ 4,707.37
2 $ 73,869.56 $ 6,155.80
3 $ 91,250.63 $ 7,604.22
4 $ 108,631.70 $ 9,052.64
5 $ 126,012.77 $ 10,501.06
6 $ 143,393.84 $ 11,949.49

To apply for services or for additional information contact
Saratoga County Resident: (518) 714 – 4004
Rensselaer County Resident: (518) 270 – 3935

Find out more about New York State Child Care Assistance Program (CCAP)
OCFS Division of Child Care Services

Click HERE to find Child Care Centers in my area
Click HERE to find out how New York State Child Care Assistance Program (CCAP) can help you pay for child care.
Do I qualify for CCAP? Click HERE to find out more.
Complete a 10-minute eligibility questionnaire by clicking Start Questionnaire Now
More Questions? Find your County contact information using the CCAP County Directory
Click HERE to find out more about the WDI Child Care Scholarship Program.
View Resources for Families HERE & Family Roadmap HERE

PLEASE REVIEW: Rates + Information

Effective March 1st, 2025

MACSC Summer Camp runs July 1st – August 22nd

July 1st – August 15th Child Care will be held onsite at Mechanicville Elementary School
25 Kniskern Ave, Mechanicville, NY 12118
August 18th – August 22nd Child Care will be held onsite at Mechanicville Area Community Services Center (MACSC)
6 South Main St, Mechanicville NY 12118

2025 MACSC Summer Camp Information
FULL Day | Hours: 7:00 a.m. – 5:00 p.m.
Accepts: Kindergarten thru 6th grade (K-6 ages 5 – 13)
Required Documentation: Completed Registration and Copy of child’s Immunization Records
**Open to Campers Monday-Friday**

Summer Camp Rates
Single Child
$60/day – $300/week

Discounts Available
Sibling Discount 25% for 2nd Child | 33% for 3rd Child
Military Discount 10%
MACSC Sponsor Discount 10%
Please Note: Discounts are available for multiple children, Veterans, employees of the Mechanicville and Hoosic Valley School Districts and employees of Corporate Partners (DeCrescente, GA Bove and Polyset)

Subsidized Care and WDI Assistance
Subsidized Care and WDI assistance are encouraged and accepted. NYS Department of Social Services (DSS) can assist low-income families who need child care to become/remain employed. Child care information and referral, Dept. of Social Services subsidized child care (as funds remain available for eligible families). Click HERE to find out more about the WDI Child Care Scholarship Program.
Please Note: Limited scholarships may be available – please inquire for a scholarship application.

Income Limits: Effective June 1st, 2024 – May 31st, 2025
Family Size Annual Monthly
1 $ 51,610.00 $ 4,300.00
2 $ 67,490.00 $ 5,624.00
3 $ 83,370.00 $ 6,947.00
4 $ 99,250.00 $ 8,270.00
5 $ 115,130.00 $ 9,594.00
6 $ 131,010.00 $ 10,917.00

To apply for services or for additional information contact
Saratoga County Resident: (518) 714 – 4004
Rensselaer County Resident: (518) 270 – 3935

Find out more about New York State Child Care Assistance Program (CCAP)
OCFS Division of Child Care Services

Click HERE to find out how New York State Child Care Assistance Program (CCAP) can help you pay for child care.
Do I qualify for CCAP? Click HERE to find out more.
Complete a 10-minute eligibility questionnaire by clicking Start Questionnaire Now
More Questions? Find your County contact information using the CCAP County Directory
Click HERE to find out more about the WDI Child Care Scholarship Program.

Volunteer Income Tax Assistance (VITA) Program is CLOSED

The Mechanicville Area Community Services Center Volunteer Income Tax Assistance (VITA) program is closed for the 2024 tax year.

If you have any further questions, please contact Andrea at 518-664-8322 ext 1003 or Dannielle at 518-664-8322 ext 1010

Check Out Our Senior Living Well Newsletter Archives!

Please take a moment to review our Archived Newsletters

2025
- January 2025, February 2025, March 2025, April 2025, May 2025, June 2025, July 2025, August 2025, September 2025, October 2025, November 2025, December 2025

2024
- January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, July 2024, August 2024, September 2024, October 2024, November 2024, December 2024

PLEASE REVIEW AND COMPLETE

The Mechanicville Area Community Services Center Holiday Assistance is CLOSED. This program will return for Christmas 2025. Sign-Ups for this program will be available early September 2025. Please check back for additional information as it gets closer to Fall 2025.

Tentative Holiday Assistance Sign-Up Date: Monday, September 8th, 2025
Tentative Holiday Assistance Distribution + Shopping Day Date: Tuesday, December 16th, 2025 for 9:00 a.m. – 1:00 p.m.

For questions and concerns please contact us at (518) 664-8322 ext 1010

Virtual VITA Sites

The CA$H Coalition offers FREE VITA tax preparation in Albany, Columbia, Greene, Rensselaer, Saratoga, Schenectady, and Schoharie counties. VITA sites may offer in-person, drop-off, or virtual tax preparation options. Please check with 211 or the VITA site for more information.

Appointments Required.

Albany County

Albany Community Action Partnership
333 Sheridan Ave., Albany
Call 2-1-1 for an appointment

Albany Public Library
161 Washington Ave., Albany

Catholic Charities of the Diocese of Albany
40 North Main Ave., Albany
Call 2-1-1 for an appointment

Catholic Central School
347 Old Loudon Rd., Latham

RCS Community Library
95 Main St., Ravena

SUNY Albany Husted Hall
135 Western Ave., Albany
Call 2-1-1 for an appointment

Trinity Alliance
15 Trinity Pl., Albany
(518) 449-5155 Ext. 102

Columbia County

Columbia Opportunities
540 Columbia St., Hudson
(518) 828-4611

Greene County

Community Action of Greene County
7856 Route 9W, Catskill
(518) 943-9205

Montgomery County

Fulmont Community Action Agency
20 Park St., Fonda
(518) 853-8356

Rensselaer County

Commission on Economic Opportunity (CEO)
2328 Fifth Ave., Troy
(518) 272-6012

Hoosick Falls VITA
26 John St., Hoosick Falls
Call 2-1-1 for an appointment

Hudson Valley Community College
80 Vandenburgh Ave., Troy
Call 2-1-1 for an appointment

Saratoga County

CAPTAIN Community Human Services
5 Municipal Plaza, Suite 3, Clifton Park
Call 2-1-1 for an appointment

Lifeworks Community Action
39 Bath St., Ballston Spa
(518) 288-3206

Mechanicville Area Community Services Center
6 South Main St., Mechanicville
Call 2-1-1 for an appointment

Schenectady County

Phyllis Bornt Branch Library
948 Stater St., Schenectady

Union College at Schenectady Public Library
99 Clinton St., Schenectady

Schoharie County

Schoharie County Community Action Program
795 East Main St., Suite 5, Cobleskill
(518) 234-2568

Thanksgiving Distribution Sign-Up CLOSED

The Mechanicville Area Community Services Center Thanksgiving Basket Distribution Sign-Up is CLOSED. This program will return for Thanksgiving 2025. Sign-Ups for this program will be available early October 2025. Please check back for additional information as it gets closer to Fall 2025.

Tentative Thanksgiving Basket Sign-Up Date: Friday, October 24th, 2025
Tentative Thanksgiving Basket Distribution Date: Saturday, November 22nd, 2025

For questions and concerns please contact us at (518) 664-8322 ext 1001

Sign Up CLOSED

The Mechanicville Area Community Services Center Winter Coat Drive is CLOSED. This program will return for 2025-2026 School Year. Sign-Ups for this program will be available early July 2024. Please check back for additional information as it gets closer to Summer 2025.

Tentative Winter Coat Sign-Up Date: Monday, June 30th, 2025
Tentative Winter Coat Distribution Date: Thursday, August 28th, 2025, 9am-2pm

For questions and concerns please contact us at 518-664-8322

PLEASE REVIEW: Rates + Site Locations

Effective August 15th, 2024
Before/After Care and half days will be held onsite at School locations.

MACSC Site Locations
Mechanicville Elementary School (housed at the MES for its 3^rd School Year)
Runs: Sept – June
Regular Hours: AM 7:00 a.m. – 9:00 a.m. | PM 3:00 p.m. – 5:30 p.m.
Half Day Hours: AM 7:00 a.m. – 9:00 a.m. | PM 11:30 p.m. – 5:30 p.m.
Accepts: Kindergarten thru 5th grade (ages 5 – 12)

Hoosic Valley School
Runs: Sept – June
Regular Hours: AM No AM Care offered | PM 2:15 p.m. – 5:30 p.m.
Half Day Hours: AM No AM Care offered | PM 11:15 p.m. – 5:30 p.m.
Accepts: Kindergarten thru 6th grade (ages 5 – 13)

All rates subject to change for the 2024-25 School Year

2024-2025 SACC School Year Rates
Single Child
$19.00/day (AM Care)
$22.00/day (PM Care)
$29.00/day (AM + PM Care)

Additional Rates
Half Day
$28.00/day (PM Care ONLY)
$35.00/day (AM + PM Care)

School Vacations ONLY (December, February and April)
$43.00/day (ALL Day Care)

Discounts Available
Sibling Discount 25% for 2nd Child | 33% for 3rd Child
Military Discount 10%
MACSC Sponsor Discount 10%
Please Note: Discounts are available for multiple children, Veterans, employees of the Mechanicville and Hoosic Valley School Districts and employees of Corporate Partners (DeCrescente, GA Bove and Polyset)

Subsidized Care and WDI Assistance
Subsidized Care and WDI assistance are encouraged and accepted. NYS Department of Social Services (DSS) can assist low-income families who need child care to become/remain employed. Child care information and referral, Dept. of Social Services subsidized child care (as funds remain available for eligible families). Click HERE to find out more about the WDI Child Care Scholarship Program.
Please Note: Limited scholarships may be available – please inquire for a scholarship application.

Income Limits:
Family Size Annual Monthly
1 $ 56,488.48 $ 4,707.37
2 $ 73,869.56 $ 6,155.80
3 $ 91,250.63 $ 7,604.22
4 $ 108,631.70 $ 9,052.64
5 $ 126,012.77 $ 10,501.06
6 $ 143,393.84 $ 11,949.49

To apply for services or for additional information contact
Saratoga County Resident: (518) 714 – 4004
Rensselaer County Resident: (518) 270 – 3935

Find out more about New York State Child Care Assistance Program (CCAP)
OCFS Division of Child Care Services

Click HERE to find Child Care Centers in my area
Click HERE to find out how New York State Child Care Assistance Program (CCAP) can help you pay for child care.
Do I qualify for CCAP? Click HERE to find out more.
Complete a 10-minute eligibility questionnaire by clicking Start Questionnaire Now
More Questions? Find your County contact information using the CCAP County Directory
Click HERE to find out more about the WDI Child Care Scholarship Program.
View Resources for Families HERE & Family Roadmap HERE

Summer Youth Drop In Registration is CLOSED

The Mechanicville Area Community Services Center Summer Youth Drop In Program is Coming Soon!! We are in the process of tailoring a FUN and EXCITING drop-in program just for YOUTH. Take a moment to complete the Summer Interest Survey and share your thoughts! This program is CLOSED until Summer 2024. Please check back early May 2024 for additional information.

Click HERE to complete the Summer Interest Survey

Tentative Summer Youth Drop-In Registration Date: Monday, May 13th, 2024

For questions and concerns please contact us at 518-664-8322

GOTR 2023

GOTR 2022

GOTR 2021

Tammy & Jessie Memorial Golf Tournament 09/24/22

Tammy & Jessie Memorial Golf Tournament 09/23/23

Tee Off Against Domestic Violence 06/24/23

Tee Off Against Domestic Violence 06/25/22

Anything That Floats 04/03/22

Anything That Floats 04/02/23

LAC du SAINT SACREMENT 08/09/22

	YES, Client Plans to self-resolve	YES, Client agreeable to referral	NO
1. In the last 12 months, did you ever eat less than you felt you should because there was not enough money for food?
2. In the last 12 months, has your utlity company shut off your service for not paying your bills?
3. Are you worried that in the next 2 months you may not have stable housing?
4. Do problems getting childcare make it difficult for you to work or study (if no children, please select N/A)
5. In the last 12 months, have you needed to see a doctor, but could not because of cost?
6. In the last 12 months, have you ever had to go without health care because you did not have a way to get there?
7. Do you ever need help reading hospital materials?
8. Are you afraid you might be hurt in your apartment building or house?
9. Have you seen a primary care provider in the last 12 months?
10. Are you currently enrolled in Medicaid Managed Care Plan with an “active” status
11. Do you require assistance accessing your prescriptions?