In Memory of Al Dorn

It is with a heavy heart that all of us at MACSC share the passing of longtime dedicated Board Member, philanthropist and volunteer, Al Dorn. From countless hours volunteering in the food pantry, soothing crying newborns by singing German lullabies, endless trips to the Regional Food Bank for pickups, afternoons spent offering homework help, and attendance at MACSC events and board meetings, most who know the community center know Al. We send Carol and Al’s entire family strength and love during this difficult time – and, we say – Thank You Al.

Jan 30 / 2023

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 contact Marie Abraham at 518-664-8322 ext 1010 or Andrea Cowell at 518-664-8322 ext 1003

	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?