check

Health Pachanga Intake

Pre session & education assessment 

Thank you for taking the time to fill out this information we value your privacy and all information is kept confidential. By filling out this assessment you are making it possible for us to continue to provide and improve our free and affordable services and education for the community. This helps us determine what programs/services you are eligible for.  

Click the button below to start.

Start

Question 1 of 20

First and Last Name

Question 2 of 20

Date Of Birth 

Question 3 of 20

Gender Identity 

A

Male

B

Female

C

Transgender

D

NonBinary

E

Gender Queer

F

Two Spirit

G

Not Listed

Question 4 of 20

Race/Ethnicity

(Select all that apply)
A

Indigenous, American Indian or Alaskan Native

B

Asian

C

Black or African American

D

Chicano/a, Xicano/a, Hispanic or Latino

E

Native Hawaiian or other Pacific Islander

F

White Non-Latino or Caucasian

G

Other Race

H

Not Reported

Question 5 of 20

Phone 

Question 6 of 20

Email Address 

Question 7 of 20

Zip Code 

Question 8 of 20

How many people are in your household?

A

1

B

2

C

3

D

4

E

5+

Question 9 of 20

What HEAL services would you like to receive for HEALTH

(Select all that apply)
A

Promotroa Training; home health party, or multiple sessions

B

Platica (Heart-to heart conversations). Wellness Navigation & Individual Support

C

Indigenous & alternative healing practices (Curanderismo, Tibetan cranial, Thai massage, Bodytalk, Body Intuitive, Reiki, Herbs, essential oils)

D

Heart Health Screening

E

Open or curious to new healing pathways

Question 10 of 20

What HEAL EDUCATION classes would you like?

(Select all that apply)
A

Culture: Celebrations, Historical trauma & resilience, history of the Americas, Indigenous history

B

Sexuality; gender, gender identity, and sexual orientation, sexual health (STI's, HIV, pregnancy)

C

Substance misuse; Harm reudction, stages of change, overdose prevention, addiction

D

Food as Medicine~ Heart Health; gardening, heart healthy cooking, indigenous growing practices, nutrients, whole foods for wellness, plant based nutrition, gut health, food quality, environmental impact, seasonal eating, cardiovascular disease prevention

E

Mental resilience; healthy coping mechanisms for trauma, depression, anxiety

F

Violence; Define different types of violence (e.g., physical, emotional, sexual, systemic). Understand root causes (e.g., trauma, power and control, systemic oppression). Recognize signs and symptoms in individuals and communities. Explore the impact of violence on health, families, and communities. Identify tools for prevention, safety planning, and healing.

Question 11 of 20

What HEAL ART classes would you be interested in participating in?

(Select all that apply)
A

Online art workshops (live and pre-recorded)

B

Community art projects; Somos Agua or Somos Tierra, murals

C

Conocimientos; Getting to know you, at home interactive kits

D

Storytelling; in persona and digital

E

Wellness crafts; essential oil mixtures & blends, salt baths, salves

Question 12 of 20

What HEAL LEADERSHIP trainings are you interested in?

(Select all that apply)
A

Policy and advocacy; knowing the process of local and national advocacy

B

Civic engagement; how to get involved locally

C

Learn about networks specifically for housing policy, environmental, immigration, economic, health policy

Question 13 of 20

What are your barriers to health & wellness 

(Select all that apply)
A

Language

B

No insurance

C

Transportation

D

Finances

E

I want to, but can't make myself

Trauma & Victimization Risk Factors

This section will address special needs for survivors of trauma, crime and victimization.  ***You must be a victim of crime to be eligible for free wellness clinic services***

Question 15 of 20

Are you a survivor of Trauma and/or crime?  *Even if not reported

A

Yes

B

No

C

I Don't Know

Question 16 of 20

If yes, do any of these apply to you? Check all that apply 

(Select all that apply)
A

N/A

B

Adult Physical Assault (Includes Aggravated and Simple Assault)

C

Adult Sexual Assault

D

Adults Sexually Abused/Assaulted as Children

E

Arson

F

Bullying (Verbal, Cyber or Physical)

G

Burglary

H

Child Physical Abuse or Neglect

I

Child Pornography

J

Child Sexual Abuse/Assault

K

Domestic and/or Family Violence

L

DUI/DWI Incidents

M

Elder Abuse or Neglect

N

Hate Crime

O

Human Trafficking: Labor

P

Human Trafficking: Sex

Q

Identity Theft/Fraud/Financial Crime

R

Kidnapping (non-custodial)

S

Kidnapping (custodial)

T

Mass Violence (Domestic/International)

U

Other Vehicular Victimization (e.g., Hit and Run)

V

Robbery

W

Stalking/Harassment

X

Survivors of Homicide Victims

Y

Teen Dating Victimization

Z

Terrorism (Domestic/International)

AA

Other

Question 17 of 20

What age(s) at the time of victimization?

(Select all that apply)
A

Age 0-12

B

Age 13- 17

C

Age 18- 24

D

Age 25- 59

E

Age 60 and Older

F

Not Reported

G

Ongoing

Question 18 of 20

Any special classification(s) that participant self-reported?

(Select all that apply)
A

Deaf/Hard of Hearing

B

Unhoused

C

Immigrants/Refugees/Asylum Seekers

D

LGBTQIA+

E

Victims with Disabilities: Cognitive/ Physical /Mental

F

Veterans

G

Victims with Limited English Proficiency

H

Other

I

None

Question 19 of 20

Do you need assistance with a victim compensation application?

A

Yes

B

No

C

I Don't Know

Question 20 of 20

Who referred you or helped you fill out this form

Confirm and Submit