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ADDITIONAL QUALIFYING QUESTIONS

  • 42. Have you taken any anti-depressants, anti-psychotics, or anti-anxiety medications in the past six months?

  • 43. Have you ever taken anti-depressants, anti-psychotics, or anti-anxiety medications during a pregnancy? (Note: we will request medical records.)

  • 44. Have you ever had a psychiatric hospitalization? If yes, when, where, and for how long?

  • 45. Have you ever been diagnosed with any of the following? Check all that apply. (Please note: review of medical records is part of the screening process.)

  • 46. Has any member of your current household or immediate family ever been diagnosed with any of the following mental illnesses: Schizophrenia, Bipolar Disorder, Severe Depression/Anxiety or Post Traumatic Stress Disorder? If yes, list who and give details.

  • 47. Have you or anyone in your household been convicted of a felony? (Please note: screening will involve a criminal background check on all adults in your household.)

    • When? What was the charge? What was the outcome (e.g. jail time, probation, community services, dimsissed)?

  • 48. Is any member of your household a registered sex offender?

  • 49. Are you receiving any of the following additional forms of government financial assistance? (Check all that apply.)

    • Which of the following describes your Medicaid enrollment?