Great Lawrence Family Health Center
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Primary Health Care
Urgent Care
Behavioral Health
Pediatric Care
Geriatric Care
Transgender Care
HIV Care Management
School-Based Health Centers
Sports Medicine
Women’s Health
Health Care for the Homeless
Office-Based Addiction Treatment
Healthy Living
Community-Based Services
For Patients
Welcome to GLFHC
Pre-Registration Process / Proceso de Pre-Registración
Find a Doctor
Patient Feedback
Community Resources
Pharmacy
Retail Pharmacy
Clinical Pharmacy Services
Pharmacy Residency Program
Locations & Hours
Full List of Locations
Methuen Family Health Center
Haverhill Family Health Center
School-Based Health Centers
Residency
AHEC
News
News
Events
Blog
Publications
About
Leadership Team
Meet Our Doctors
Corporate and Philanthropic Partners
Join Our Team
Sign Up for Updates
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Your name
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In the last 12 months, have you been threatened with eviction or foreclosure or been forced to move? Or, are you worried that this is a risk in the next 3 months?
Yes
No
Are you worried about the conditions of your housing (infestation, mold, overdue repairs)?
Yes
No
Do you ever have trouble making ends meet at the end of the month?
Yes
No
In the last 12 months, have you worried that your food would run out before you got money to buy more?
Yes
No
In the last 12 months, has the food you bought not lasted and there was no money to buy more?
Yes
No
How often do you need to have someone help you when you read instructions, pamphlets, or other written materials from your doctor or pharmacy?
Yes
No
Are you concerned about your family's health and stability for any immigration-related reason?
Yes
No
In the last 12 months, have you or anyone in your family missed a medical appointment due to lack of transportation?
Yes
No
In the past 12 months has the electric, gas, oil or Water Company threatened to shut off services in your home?
Yes
No
Have you been hit, kicked, punched, or otherwise hurt by someone in the last year?
Yes
No
How often do you feel lonely or isolated from those around you?
Very Often
Often
Sometimes
Occasionally
Never
Are you interested in receiving a handout with further information about resources?
Yes
No
Are you interested in being referred to a community health worker to discuss further?
Yes
No
If you are a PARENT filling this out for a child, do these answers also apply to you?
Yes
No
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