MSNY Client Intake

Confidential Benefits Screening

The secure assessment to connect you with the free Food, Housing, and Transportation you deserve.
Section 1: Client Info
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
What type of Health Insurance do you have?*

Medicaid (Common Benefit / NYS Health)Medicare (Red, White, & Blue Card)I have BOTH Medicaid and MedicarePrivate Insurance / Employer InsuranceI do not have insuranceI am not sure
Section 2: Housing & Utilities
What is your living situation today?*

I have a steady place to liveI have a place to live today, but I am worried about losing it in the futureI do not have a steady place to live (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)
Think about the place you live. Do you have problems with any of the following? (Check all that apply)*

Pests such as bugs, ants, or miceMoldLead paint or pipesLack of heatOven or stove not workingSmoke detectors missing or not workingWater leaksNone of the aboveOther
In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?*

YesNoAlready shut off
Section 3: Food Security
Within the past 12 months, you worried that your food would run out before you got money to buy more.*

Often trueSometimes trueNever true
Within the past 12 months, the food you bought just didn't last and you didn't have money to get more.*

Often trueSometimes trueNever true
Section 4: Transportation
In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?*

YesNo
Section 5: Employment & Education
Do you want help finding or keeping work or a job?*

Yes, help finding workYes, help keeping workI do not need or want help
Do you want help with school or training? (For example, starting or completing job training or getting a high school diploma, GED or equivalent)*

YesNo
Section 6: Interpersonal Safety

We ask all our clients the following questions because your safety at home is just as important to your health as food and housing.
How often does anyone, including family and friends, physically hurt you?

NeverRarelySometimesFairly oftenFrequently
How often does anyone, including family and friends, insult or talk down to you?

NeverRarelySometimesFairly oftenFrequently
How often does anyone, including family and friends, threaten you with harm?

NeverRarelySometimesFairly oftenFrequently
How often does anyone, including family and friends, scream or curse at you?

NeverRarelySometimesFairly oftenFrequently
Disclaimer & Consent
By signing below, I give MetroScout New York permission to use the information I provided to help me apply for Medicaid Social Care Network (SCN) benefits, such as food, housing, and transportation assistance.

I understand and agree to the following:
- Contact: MetroScout NY may contact me by phone, text message, or mail to follow up on my application.
- Sharing: My information may be shared with social care providers, Medicaid Social Care Networks (SCN), and government agencies (like Medicaid or Public Health Solutions) strictly for the purpose of getting me these benefits.
- No Guarantees: MetroScout NY is here to help navigate the system, but the final decision to approve benefits comes from the government/insurance plan, not MetroScout NY.
- Privacy: My data will be kept private and only used to help me get services.
*

Yes, I have read, understand, and agree.
Client Signature*
Date

MonthDayYear
Date
Safety Score
Risk Flag
Billability
Should be Empty:

Confidential Benefits Screening

Section 1: Client Info

Section 2: Housing & Utilities

Section 3: Food Security

Section 4: Transportation

Section 5: Employment & Education

Section 6: Interpersonal Safety

Disclaimer & Consent