SAGEServes Universal Form
Today's Date:
Do you live at any of SAGE's LGBTQ+-Friendly Housing Buildings?
SAGE Stonewall House
SAGE Crotona Pride House
No
SAGE PROGRAM INTEREST:
SAGE Centers
SAGE Care Management
REGISTRATION SITE: (
Check the sites you'd like to register at
)
SAGE Center Midtown - Edie Windsor Center
SAGE Center Harlem
SAGE Center at Stonewall House
SAGE Center Bronx at Crotona Pride House
SAGE-Pride Center of Staten Island
How did you hear about SAGE? (
Check all that apply
)
Facebook/Twitter Website
Pride or Tabling Event
TV News/Magazine
SAGE Outreach & Materials
Friend or Family
Google/Search Engine
Other Agency
SAGE Special Events
Other
If other, how did you hear about SAGE?
Legal First Name:
Legal Last Name:
Name you would like to be called:
Date of Birth:
Please use the format of two digit month, two digit day and four digit year separated by slashes (/)
x
Mailing Address
Street Address:
Please be sure to include your apartment number, if applicable.
City:
State:
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Borough:
Please select...
Brooklyn
Bronx
Manhattan
Queens
Staten Island
NYS/Outside of NYC
Outside of NYS
Zip code:
Do you reside in a NYCHA Facility?
Yes
No
I don't know
NYCHA Facility Name:
Are you currently homeless?
Yes
No
Prefer not to answer
Are you more comfortable speaking a language other than English?
Yes
No
Which language do you prefer?
Communication Needs:
None
Hearing Impaired
Sight impaired
Speech Impaired
Other
If other, please describe:
Contact Information
Email Address:
Do you have internet access at home?
Yes
No
I don't know
Home Phone Number:
Mobile Phone Number:
What methods are you comfortable with SAGE using to contact you?
Phone Call
Email
Text
None
Monthly Household Income:
Annual Household Income (Required by the Department for the Aging)
Under $11,670
$11,670-15,730
$15,731-$17,504
$17,505-$19,790
$19,791-$23,595
$23,596-$23,850
$23,851-$27,910
$27,911-$29,685
$29,686-$31,970
$31,971 or above
Prefer not to answer
Source of income:
Full-Time Employment
Part-Time Employment
Veterans Benefits
Public Assistance
SSI/SSD
Savings
Off the Books
Sex Work
Pension/Retirement
Supported by Others
Not Listed
Prefer not to answer
What best describes your sexual orientation?
Please select...
Lesbian
Gay
Bisexual
Same Gender Loving
Heterosexual/Straight
Queer
Asexual
Unsure/Questioning
Do Not Identify
Prefer not to answer
Not listed
If not listed, please describe
What best describes your gender identity: (Check all that apply)
Please select...
Female/woman
Male/man
Trans female/Trans woman
Trans male/Trans man
Gender nonconforming/Genderqueer
Intersex
Prefer not to answer
Not listed
If not listed, please describe
What sex were you assigned at birth? (meaning, on your original birth certificate)
Female
Male
Intersex
What pronouns do you use?
She/her/hers
They/their/theirs
He/him/his
Other
Prefer not to answer
Other pronouns:
Race (check all that apply):
Black or African American
White
Latinx/Hispanic
Asian, Native Hawaiian or Pacific Islander
American Indian/Alaskan Native
Arab, Middle Eastern
Multi-Racial
Do not identify
Prefer not to answer
Ethnicity:
Hispanic
Non-Hispanic
Prefer not to answer
Relationship Status:
Domestic Partner
Married
Partnered
Widowed
Divorced
Separated
Single
Prefer not to answer
What is your highest level of education achieved?
Less than a high school diploma
Trade School Completion
High School diploma (GED)
Some College
Associate's degree
Bachelor's degree
Master's degree or higher
Prefer not to answer
Did you serve in the US Military?
Yes
No
Has your legal spouse served in the US Military?
Yes
No
Do you live alone?
Yes
No
With whom do you live?
Partner
Spouse
Roommate
Family
Friend
Pet
Not listed
If not listed, please tell us whom:
Do you have a plan for your pet in the event of an emergency?
Yes
No
Are you currently living with a disability or any chronic medical condition?
Yes
No
What chronic medical condition?
Allergies
Arthritis
Cancer
Cognitive Impairment
Dental Problems
Diabetes
Hearing Impairment
Heart Disease
High Blood Pressure
HIV
Incontinence
Memory Problems
Mobility Issues
Respiratory Problems
Stroke
Visual Impairment
Not Listed
Prefer not to answer
What other chronic medical condition:
Are you currently living with any chronic mental health condition?
Yes
No
What chronic mental health condition?
Anxiety
Bipolar Disorder
Depression
Substance Abuse
Grief/Loss
Not Listed
Prefer not to answer
What other mental health condition:
Check all that apply:
Use a walker
Wheelchair dependent
Legally Blind
Use a respirator
On dialysis
Frail/Disabled
Insulin dependent
Oxygen dependent
Have an Air Conditioner
History of heat insufficiency
Memory Problems
Home bound
Will be unassisted in an emergency
In the event of an emergency (i.e. natural disaster, blackout, heatwave, etc.) should SAGE do outreach to you?
Yes
No
Emergency Contact
Contact Name:
Contact Phone:
Relationship to you:
Is Emergency Contact also your Health Care Proxy?
Yes
No
Registration Type
Online Self-Registration
Page 2 of 4
Nutritional Health
Do you have an illness/condition that makes you change the kind and/or amount of food you eat?
Yes
No
Do you eat fewer than 2 meals per day?
Yes
No
Do you eat fewer than 2 daily servings of fruits?
Yes
No
Do you eat fewer than 2 daily servings of vegetables?
Yes
No
Do you eat fewer than 2 daily servings of milk product?
Yes
No
Do you have 3 or more drinks of beer, wine, or liquor almost every day?
Yes
No
Do you have tooth or mouth problems that make it hard for you to eat?
Yes
No
I don't always have enough money to buy the food I eat
True
False
Do you
eat alone most of the time?
Yes
No
Do you
take 3 or more different prescribed or over-the-counter drugs daily?
Yes
No
Without wanting to, have you lost or gained 10lbs. in the past 6 months?
Yes
No
I am not always physically able to shop, cook, and/or feed myself
True
False
Do you have a special diet?
Yes
No
What type of diet?
Vegetarian
Vegan
Pescatarian
Kosher
Gluten-free
Low-sodium
Diabetes
Not Listed
What other type of diet?
Page 3 of 4
Duke Social Support Index
1. How many people in your local area do you feel that you can depend on or feel very close to?
None
1-2
More than 2
2. How many times during the past week did you spend time with someone who does not live with you, (you went to see them, they came to visit you, or you went out together)?
None
Once or twice
3-5 times
6 or more times
3. How many times did you talk to someone (friends, chosen family, relatives or others) on the telephone in the past week (either they called you, or you called them)?
1 or fewer times
2-5 times
6 or more times
4. About how often did you go to meetings of clubs, community groups, or other groups that you belong to in the past week?
1 or fewer times
2-5 times
6 or more times
For this section, "people who are important to you" refers to any personal relationships that feel important to you. This does not include paid professionals who provide services, such as social workers, home care attendants, doctors, religious leaders, etc.
5. I feel that the people who are important to me understand me.
Hardly ever
Sometimes
Most of the time
6. I feel useful to the people who are important to me.
Hardly ever
Sometimes
Most of the time
7. I know what is going on in the lives of the people who are important to me.
Hardly ever
Sometimes
Most of the time
8. When I am talking with the people who are important to me, I feel I am being listened to.
Hardly ever
Sometimes
Most of the time
9. I feel I have a definite role in the lives of the people who are important to me.
Hardly ever
Sometimes
Most of the time
10. I can talk about my deepest problems with at least some of the people who are important to me.
Hardly ever
Sometimes
Most of the time
Page 4 of 4
Which of these would you consider your current support system? (Check all that apply)
Spouse/Partner
Friends
Family Members
Neighbors
Therapist/Counselor/Case Manager
Spiritual/Religious Community
Online Communities
Pets
Community or Senior Center
Not Listed
None
If not listed, what other support system?
Are you currently receiving help from a social worker or case manager at another organization/agency?
Yes
No
Name of worker(s)
Number/email of worker(s)
Are you involved with taking care of someone or is someone helping to take care of you?
Yes
No
Do you have health insurance?
Yes
No
Which of the following do you have?
Medicaid
Medicare
ADAP
Private Individual Insurance
Insurance through employer
Medicaid #:
Medicare #:
Are you currently receiving any of the following benefits or services?
SNAP
SCRIE
DRIE
Medicare Extra Help
HEAP
EPIC
Access-a-Ride
PERS
Meals on Wheels/God's Love
Food Pantries
Public Assistance
Not Listed
None
What other benefit or service?
Do you have a home attendant of other home services?
Yes
No
What services?
Personal Care
Companionship
Housekeeping
Not Listed
How many hours per week?
0-4 hours
5-9 hours
10 or more hours
Do you have any of these advance planning documents in place?
Healthcare Proxy
Living Will
Power of Attorney
Last Will and Testament
Not Listed
None
Where are these documents located?
In the event of an emergency, who has access to these documents?
Please enter name and phone number of person who has access to documents
Are you interested in learning more about Advance Care Planning?
Yes
No
In the past year, have you been afraid of your...? (Check all that apply)
Current Partner
Ex-Partner
Family Member
Caregiver
Not Listed
No One
Health
Overall how would you rate your health during the past four (4) weeks:
Excellent
Very good
Good
Fair
Poor
Very Poor
During the past 4 weeks, how much did physical health problems limit:
Not at all
Slightly
Moderately
Quite a bit
Almost Totally
Physical Activities (walking, climbing stairs)
Your daily activities at home (bathing, cooking, cleaning)
Your daily activities outside your home (shopping, errands, laundry)
Your social activities with family and friends
How much bodily pain have you had during the past 4 weeks?
None
Very Mild
Mild
Moderate
Severe
Very Severe
During the past 4 weeks, how much energy did you have?
None
A little
Some
Quite a lot
Very Much
In the past 6 months, have you experienced a fall?
None (0)
1-2 times
3-4 times
5 or more
By fall, we mean when a person unintentionally comes to rest on the ground or another level.
In the past 6 months, how many times did you visit a hospital emergency room?
None (0)
1-2 times
3-4 times
5 or more
Do you have a primary care physician?
Yes
No
Primary Physician Name:
Primary Physician Address:
Primary Physician Phone #:
Primary Physician Email:
Would you like to learn more about supportive services and/or care management offered at SAGE?
Yes
No