Evaluating Community Health and Well-being – Check Your Status

Enter the current date:

Enter some general information:

Enter some additional information.

Enter your date of birth:

Specify the last four of your Social Security Number:

Enter your Marital Status:

SingleMarriedDivorcedWidowed

Please answer the 4 questions below to help us understand your concerns and needs surrounding your physical and mental health.

1. Please select one that best describes your general health:

ExcellentVery GoodGoodFairPoor

2. Regarding your physical health (including physical illness and injury) how many days during the past month did you experience poor physical health?

3. Regarding your mental health (including stress, depression and problems with emotions) how many days during the past month did you experience poor mental health?

4. During the past 30 days, did poor physical or mental health keep you for doing your usual activities, such as work, self-care or recreation?

YesNo

4a. If Yes was selected above, how many days?

Way to Go! You are taking good care of yourself.

If you ever need any extra support please call 502-694-8170 or email HEROES@FamilyScholarHouse.org You can also find additional resources on our free web-app at LouieConnect.com

Visit LouieConnect.com

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You’re on the right track!

If you’d like additional resources, check out our free web-app at LouieConnect.com If you ever need any extra support please call 502-694-8170 or email HEROES@FamilyScholarHouse.org

Visit LouieConnect.com

Connect with Us

Looks like you could use some support.

We can help. Please call 502-694-8170 Or email HEROES@FamilyScholarHouse.org for more information. You can also find additional resources on our free web-app at LouieConnect.com

Visit LouieConnect.com

Connect with Us

If you ever need any extra support please call 502-694-8170 or email HEROES@FamilyScholarHouse.org. You can also find additional resources on our free web app at LouieConnect.com.

Connect with Us