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Adventist Health Clearlake
E-Center WIC
Easterseals NorCal
First 5 Lake County
Lake County Behavioral Health
Lake County Office of Education
Lake County Public Health
Lake County Social Services
Lake County Tribal Health
Lake Family REsource Center
Mother-Wise
North Coast Opportunities
Partnership Health Plan
Redwood Coast Regional Center
Redwood Community Services
Sutter Lakeside Hospital
Other Provider
Name
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First Name
Last Name
Date of Birth
Month
1
2
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9
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11
12
Day
1
2
3
4
5
6
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31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
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2000
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1991
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1986
1985
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1982
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1958
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1955
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1942
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1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Phone
Email
*
ZIP Code
*
95422
95423
95424
95426
95435
95443
95451
95453
95457
95458
95461
95464
95467
95485
95493
Race / Ethnicity
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Hispanic/Latino
Multiple Races
Other
Language Preference
English
Spanish
Other
Gender
Female
Male
Other or Not Disclosed
Disability Status
I am disabled
Number of People Living in Household
1
2
3
4
5
6
7
8
9+
Are you or your partner pregnant?
Yes
Due Date
MM slash DD slash YYYY
Are You Experiencing a High Risk Pregnancy?
Yes
Do you need to travel outside Lake County for medical appts related to pregnancy?
Yes
Employment Status
Unemployed Seeking Employment
Unemployed Not Seeking Employment
Student
Employed Full Time
Employed Part Time
Self Employed
Monthly Household Income Before Taxes
$0 - $1,437
$1,438 - $1,810
$1,811 - $2,183
$2,184 - $2,557
$2,558 - $2,930
$2,931 - $3,303
$3,304 - $3,677
$3,678 - $4,040
$4041 - $4730
$4731 - $5421
$5422 - $6112
$6113 - $6802
$6803+
*Best Guess
Housing Status
Own home
Renting a house / apartment / room
Living with friend / family temporarily
Living in a hotel / motel
Living in car / park / campground / public space
Check all that apply
I am Enrolled in Medi-Cal (Partnership Health Plan)
I Recieve TANF or CalWorks
I Recieve Calfresh/Food Stamps
I want information about quitting tobacco/nicotine
I am concerned about health effects of second hand smoke, third hand smoke or vaping
Dependents
- Including Babies in Utero
Dependents
Name
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