NYS ACCOUNTABLE HEALTH COMMUNITIES (ACH) HEALTH - RELATED SOCIAL NEEDS SCREENING TOOL (HRSN)
In collaboration with SOMOS Social Care Network, 2910 Exterior St, Bronx NY 10463
CONSENT: We use this survey to understand needs our Members have which could interfere with good health. We may share your answers with your other healthcare providers, and with your health plan and social services organizations, so they can determine if you qualify for any free non-medical services that could be helpful. You can choose not to answer this survey, but we can only check for services if you do answer *YES*.
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YES, I consent (You MUST answer 'YES' in order to receive services)
No, I do not consent (If chosen, no services will be provided)
PERSONAL INFORMATION
NAME:
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First Name
Last Name
MEDICAID CLIENT IDENTIFICATION # (CIN)
*
DATE OF BIRTH:
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-
Month
-
Day
Year
Date
GENDER:
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MALE
FEMALE
OTHER
PHONE NUMBER:
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-
Area Code
Phone Number
EMAIL:
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example@example.com
MY HOME ADDRESS IS:
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Street Address
Street Address Line 2
City
State
Zip Code
PREFERRED SPOKEN LANGUAGE:
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Please Select
English
Arabic
Czech
Danish
German
Greek
Spanish
Finnish
French
Frysian
Hindi
Croatian
Italian
Japanese
Korean
Dutch
Norwegian
Punjabi
Polish
Portuguese
Russian
Serbian
Swedish
Chinese
SERVICES SCREENING
LIVING SITUATION
WHAT IS YOUR LIVING SITUATION TODAY??
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I have a steady place to live
I have a place to live today, but I am worried about losing it in the future
I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)
HOUSING CONDITIONS
THINK ABOUT THE PLACE YOU LIVE. DO YOU HAVE PROBLEMS WITH ANY OF THE FOLLOWING?:
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Pests such as bugs, ants, or mice
Mold
Lead paint or pipes
Lack of heat
Oven or stove not working
Smoke detectors missing or not working
Water leaks
None of the above
UTILITIES
IN THE PAST 12 MONTHS HAS THE ELECTRIC, GAS, OIL, OR WATER COMPANY THREATENED TO SHUT OFF SERVICES IN YOUR HOME?:
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Yes
No
Already shut off
FOOD
WITHIN THE PAST 12 MONTHS, YOU WORRIED THAT YOUR FOOD WOULD RUN OUT BEFORE YOU GOT MONEY TO BUY MORE.
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Often true
Sometimes true
Never true
TRANSPORTATION
IN THE PAST 12 MONTHS, I HAVE LACKED RELIABLE TRANSPORTATION TO MEDICAL APPOINTMENTS, MEETINGS, WORK, OR GETTING THINGS NEEDED FOR DAILY LIVING?:
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Yes
No
CAREER
DO YOU WANT HELP FINDING OR KEEPING WORK OR A JOB?:
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Yes, help finding work
Yes, help keeping work
I do NOT need help
SCHOOL
Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, GED, or equivalent?
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Yes
No
NEXT STEPS & SIGNATURE
DISCLAIMER:
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I would like to continue with a Navigator within the Social Care Network for further assistance in addressing the above needs and would like to be connected to resources. I understand this information will be encrypted and sent to NYS Accountable Health Communities (AHC) for processing through the SOMOS Community Care Network. I understand more information on this program can be found at findhelp.org or somoscommunitycare.org.
YOUR SIGNATURE:
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Submit
This form was created in collaboration with:
SOMOS COMMUNITY CARE
Changing Lives, Creating a Fair Chance for Health and Wellbeing: A Future Where EVERY Person in New York Succeeds
This form can be filled out by a live operator by calling HealthfulMeals (powered by MedMeal Direct) at (504)372-0266.
AVAILABLE *VOLUNTARY* QUESTIONS
You do NOT need to answer below questions to receive navigation services.
GENDER IDENTITY:
Please Select
Male
Female
Non-Binary
Unknown
ETHNICITY:
Please Select
Hispanic of Latino
Not Hispanic or Latino
Unknown
RACE:
Please Select
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Unknown
PREFERRED PRONOUN:
Please Select
I use traditional pronouns
he/his/him/his/himself
she/her/hers/herself
they/them/their/theirs/themselves
SEXUAL ORIENTATION:
Please Select
Heterosexual
Homosexual
Bisexual
Other
Unknown
ADMINISTRATIVE GENDER:
Please Select
Male
Female
Unknown
Other
PHYSICAL ABILITY:
Please Select
I have difficulty walking or climbing stairs.
I have difficulty dressing or bathing.
Both of the above.
None of the above.
Decline to answer.
PREFERRED PHONE NUMBER:
PREFERRED ADDRESS:
*VOLUNTARY* SAFETY QUESTIONS
THE BELOW QUESTIONS ARE OPTIONAL AND DO NOT AFFECT ELIGIBILITY FOR SERVICES.
How often does anyone, including family and friends, physically hurt you?
Please Select
NEVER
RARELY
SOMETIMES
FAIRLY OFTEN
FREQUENTLY
DECLINE TO ANSWER
How often does anyone, including family and friends, insult or talk down to you?
Please Select
NEVER
RARELY
SOMETIMES
FAIRLY OFTEN
FREQUENTLY
DECLINE TO ANSWER
How often does anyone, including family and friends, threaten you with harm?
Please Select
NEVER
RARELY
SOMETIMES
FAIRLY OFTEN
FREQUENTLY
DECLINE TO ANSWER
How often does anyone, including family and friends, scream or curse at you?
Please Select
NEVER
RARELY
SOMETIMES
FAIRLY OFTEN
FREQUENTLY
DECLINE TO ANSWER
Should be Empty: