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Health Needs Assessment

Thank you for doing this survey. This survey asks questions about you and some factors that may affect your health. This information will help the Massachusetts Behavioral Health Partnership (MBHP) better understand your needs and we can use it to identify resources that may be helpful to you. Your responses are confidential and will be not used for any other purposes than finding ways that MBHP can support you.

The survey will take around 20 minutes to complete. If possible, try to complete it in one sitting. If you cannot, the questions that you have submitted will be saved and you can log in later to finish the remaining questions.

If you need help completing the survey, please call 1-800-495-0086.

Member Name:
Last *Required	First *Required	Middle
Member date of birth: *Required
Member street address:
Address line 1 *Required	Address line 2
Member city *Required	Member State *Required	Member Zip Code *Required


Address validation is required
Your address doesn't appear to be validated. Do you wish to continue using this address?: Yes No
Member Phone Number *Required
Email MemberID Email is in invalid format.
By providing this email, our care management team will be better able to send you resources and information that will support your needs. You will not be added to marketing email lists.
MassHealth Member ID *Required Minimum 12 characters required
Enter MassHealth Member ID or select the checkbox below.

I don’t know my MassHealth Member ID

Please enter the address and phone number you used to sign up for MassHealth

SSN

Same As Current Address and Phone Number

Address line 1

Address line 2

Member Phone Number

Member City

Member State

Member Zip Code