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Are you presently receiving any <br />If yes, list type and <br />benefits (Medicare/Medicaid) or do <br />YES / NO <br />benefit number(s) if <br />you have other health insurance <br />available. Make <br />coverage? <br />photocopy of card. <br />Do you need access to a 12 -step <br />YES / NO <br />List ram ro type. <br />p g <br />program? Which one? <br />Would you like to register on the Red <br />If yes, provide <br />Cross SAFE and WELL website to let <br />YES / NO <br />registration form. <br />g <br />loved ones know you are OK? <br />How? Serve food, <br />Would you be able or willing to help <br />YES / NO <br />supervise children, <br />others in the shelter? <br />organize service <br />teams, other? <br />TRANSPORTATION <br />Circle <br />Actions to be taken <br />Name of <br />Individual <br />Do you need assistance with <br />If yes, list <br />transportation? <br />YES / NO <br />destination and <br />date /time. <br />Do you have any other transportation <br />needs? <br />ADDITIONAL QUESTIONS <br />TO INTERVIEWER <br />Would this person benefit from a <br />If yes, refer to <br />more detailed health or behavioral <br />YES / NO <br />Behavioral Health <br />health assessment? <br />Services. <br />REFER to: <br />HS <br />If life threatening, <br />Does the client appear to be <br />YES / NO <br />call 911. <br />overwhelmed, disoriented, agitated or <br />DMH <br />If yes or unsure, <br />a threat to self or others? <br />YES / NO <br />refer immediately to <br />Interviewer <br />Health Services. <br />Initial <br />If no, work with <br />Can this shelter provide the <br />YES / NO <br />Behavior Health <br />assistance and support needed? <br />Services and Shelter <br />Manager. <br />If no or uncertain, <br />Has the person been able to express <br />consult with <br />his/her needs and make choices? <br />YES / NO <br />Behavioral Health <br />Services and Shelter <br />Manager. <br />HS/ DMH signature: <br />Date: <br />Cabarrus County EOP — Annex L — Shelter and Mass Care <br />Attachmen4number 12 <br />F -6 Page 303 <br />