Navigation SDOH Services Screener

The following questionnaire is designed to assess for resource needs within the five categories of the Social Determinants of Health (SDOH), which include economic stability, education access, health care access, home environment, and social and community context.

Filling out this brief form will help your Family Support Navigator know more about you and your family, and what kinds of navigation services/resource information you may be looking for. Thank you for taking the time to help us get to know you better!

Navigation Services Screener (SDOH)

Your Name(Required)

Please enter your first and last name.

First Last

Your Email(Required)

If you do not have an email address, please write “no email”

Child's Name(Required)

Please enter your child’s first and last name. If you have multiple children enrolled in the Connections program, you only need to list one of them.

First Last

Child Development

Do you have questions or concerns about how your child is developing?(Required)

If yes, please explain:

Are you interested in assistance with finding preschool or childcare options?(Required)

If yes, please explain:

Do you have other questions about what resources are available for your child(ren) such as play groups or home visiting programs?(Required)

If yes, please explain:

Would you like any information or resources on breastfeeding?(Required)

If yes, please explain:

Health

Is anyone in the household pregnant?(Required)

If yes, is that person receiving prenatal care, such as attending recommended Dr. appointments?

Does your family have a primary doctor?(Required)

If no, would you like assistance in finding a doctor?

Do members in your family have medical insurance?(Required)

If no, would you like assistance in exploring insurance options?

Does your family have a dentist?(Required)

If no, would you like assistance in exploring dental care options?

Behavioral Health and Interpersonal Safety

Within the past two weeks, have you felt like you may be experiencing symptoms of depression or anxiety?(Required)

(such as feeling down, hopeless, or little to no energy)

Within the past two weeks, have you noticed yourself withdrawing from things you used to enjoy?(Required)

(such as activities, hobbies, or spending time with loved ones)

Are you concerned about the use of substances, like alcohol or drugs, by yourself or someone in your household?(Required)

If yes, please explain:

Do you feel safe with the people in your home?(Required)

If no, do you have a safe place to go in an emergency?

Employment and Education

Would you like assistance finding or keeping employment?(Required)

If yes, please explain:

Would you like help with school or training for yourself or someone in the household?(Required)

If yes, please explain:

Housing

Do you have concerns about your housing situation?(Required)

(This could include: experiencing homelessness and/or needing to move or find alternate housing currently or in the near future.)

If yes, please explain:

Do you have concerns about the physical environment of the place you live?(Required)

(This could include: mold, lead paint, lack of heat, stove not working, pests, water leaks, or smoke alarms missing or not working)

If yes, please explain:

Are you concerned with your ability to pay for utilities?(Required)

(heat, water, gas, etc.)

If yes, would you like resources to help assist you in this area?

Food Security

Do you have enough food to feed your family each month?(Required)

If no, would you like resources to help assist you in this area?

Are you concerned about not having enough money for food?(Required)

If yes, would you like information on local food banks and other resources?

General Access

Is lack of transportation keeping you from medical appointments, meetings, work, of from getting things needed for daily living?(Required)

If yes, please explain:

Do you have reliable phone and internet services?(Required)

If no, would you like information on resources to assist you in this area?

Is there anything else you would like to share with your Family Support Navigator?