MHE - Do it yourself HEAL form

Thank you for your interest in our Do-it-Yourself Healthy Home Check-up. This form will collect basic information that will allow us to know who is accessing these resources so we can better serve our community.

  Your Information

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Name:

 

 

   

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City/State/ZIP:

 

    

 

 

 

 

 

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Question - Required - Type of HEAL form






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Question - Not Required - Race







 


 


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