• PHS Screening Form

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Client

  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Contact

  • Format: (000) 000-0000.
  • Client can Receive SMS?*
  • Address type*
  • Screening Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Screening Questions

  • 2. Do you struggle with paying for housing or find yourself falling behind on payments?*
  • 3. Do you have any concerns about the quality of your housing?*
  • 4. What specific housing issues are you experiencing? (select all that apply)*
  • 5. In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?*
  • If yes, which utilities? (select all that apply)*
  • 6. Which of the following utility issues are you experiencing? (Select all that apply)*
  • 7. Do you currently receive any assistance for utilities through any existing programs with the city or state?*
  • 8. Do any of the following issues apply to your household?*
  • 9. Do you need assistance finding or keeping work or a job?*
  • 10. Do you want help with school or training (job training, GED, high school completion)?*
  • 11. In the past 12 months has lack of reliable transportation kept you from medical appointments, meetings, work, or getting things needed for daily living?*
  • 12. Do you receive SNAP (Food Stamps)?*
  • 13. Do you receive TANF?*
  • 14. Do you have any chronic illnesses or conditions (ex: diabetes, asthma)?*
  • 15. Are there any other known health issues you may have?*
  • 16. Does this person suffer from Substance Use Disorders, Severe Mental Illnesses, Intellectual or Developmental Disabilities, or Over or Under Weight?*
  • 17. Are you enrolled in a Health Home? (A New York State Health Home is a Medicaid care management program designed for people with complex medical, behavioral health, or social service needs.)*
  • 18. Do you have any medications that require refrigeration?*
  • 19. (Women only) Are you pregnant or postpartum?*
  • *
  • *
     - -
    2 digit month, 2 digit day, 4 digit year
  • 20. Do you receive WIC?*
  • 21. Are you currently receiving home-delivered meals or food services through a New York State (NYS) social services program? (e.g. Meals on Wheels, home-delivered meals for seniors, or other food assistance programs offered by NYS)*
  • 22. Are you on any housing waitlists (e.g., HUD, Section 8, local housing authority, or other voucher programs) or receive a rental subsidy?*
  • 23. Does the member have difficulty climbing stairs or bathing?*
  • 24. Do you require refrigeration for breastmilk?*
  • 25. Do you prefer precooked meals or grocery boxes?*

  • Food Allergies / Dietary Restrictions

  • 1. Do you have food allergies?*
  • Please list allergies:*
  • 2. Do you have dietary restrictions?*
  • Please select all that apply:*

  • Household Appliance / Cooking Needs

  • 1. Does the household need a refrigerator?*
  • 2. Does the household need a microwave?*
  • 3. Does the household need cooking utensils or cooking supplies?*

  • Additional Questions

  • 1. Would having additional food support or help with groceries make things easier or reduce stress for you or your household?*
  • 2. Do you feel your household could benefit from extra food assistance, meal support or help keeping enough food in the home consistently?*
  • 3. Are you currently employed?*
  • 4. Do you receive income from any source?*
  • 5. Do you have the ability to store and prepare food such as access to a refrigerator and stove?*
  • 6. Are you currently receiving nutritional counseling or education provided through a New York State social services program?*
  • 7. Do you currently need care to recover from an illness or injury, prepare for a surgery or procedure, or transition out of a hospital or other facility?*
  • 8. Are you currently working with a housing provider or program?*
  • 9. Do you participate in the Healthy Homes Program or any similar program provided by New York State to address home environmental health hazards? (these programs help make your home safer by addressing issues like lead, paint, mold, or other environmental hazards.)*

  • Interpersonal Safety Questions

  • Household Members with Medicaid

    Adding members here will automatically create or link their client profiles using the same address and phone number. Complete identity and household screening in the add member dialog.
  • Add another household member*
  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 1. Do they need assistance finding or keeping work or a job?*
  • 2. Do they have any chronic illnesses or conditions (ex: diabetes, asthma)?*
  • 3. Are there any other known health issues they may have?*
  • 4. Does this person suffer from Substance Use Disorders, Severe Mental Illnesses, Intellectual or Developmental Disabilities, or Over or Under Weight?*
  • 5. Are they enrolled in a Health Home? (A New York State Health Home is a Medicaid care management program designed for people with complex medical, behavioral health, or social service needs.)*
  • 6. Do they have any medications that require refrigeration?*
  • 7. (Women only) Are they pregnant or postpartum?*
  • *
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 8. Are they currently receiving home-delivered meals or food services through a New York State (NYS) social services program? (e.g. Meals on Wheels, home-delivered meals for seniors, or other food assistance programs offered by NYS)*
  • 9. Does the member have difficulty climbing stairs or bathing?*
  • 10. Do they require refrigeration for breastmilk?*

  • Food Allergies / Dietary Restrictions

  • Do they have food allergies*
  • Please list allergies:*
  • Do they have dietary restrictions?*
  • Please select all that apply:*
  • Add another household member*
  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 1. Do they need assistance finding or keeping work or a job?*
  • 2. Do they have any chronic illnesses or conditions (ex: diabetes, asthma)?*
  • 3. Are there any other known health issues they may have?*
  • 4. Does this person suffer from Substance Use Disorders, Severe Mental Illnesses, Intellectual or Developmental Disabilities, or Over or Under Weight?*
  • 5. Are they enrolled in a Health Home? (A New York State Health Home is a Medicaid care management program designed for people with complex medical, behavioral health, or social service needs.)*
  • 6. Do they have any medications that require refrigeration?*
  • 7. (Women only) Are they pregnant or postpartum?*
  • *
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 8. Are they currently receiving home-delivered meals or food services through a New York State (NYS) social services program? (e.g. Meals on Wheels, home-delivered meals for seniors, or other food assistance programs offered by NYS)*
  • 9. Does the member have difficulty climbing stairs or bathing?*
  • 10. Do they require refrigeration for breastmilk?*

  • Food Allergies / Dietary Restrictions

  • Do they have food allergies*
  • Please list allergies:*
  • Do they have dietary restrictions?*
  • Please select all that apply:*
  • Add another household member*
  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 1. Do they need assistance finding or keeping work or a job?*
  • 2. Do they have any chronic illnesses or conditions (ex: diabetes, asthma)?*
  • 3. Are there any other known health issues they may have?*
  • 4. Does this person suffer from Substance Use Disorders, Severe Mental Illnesses, Intellectual or Developmental Disabilities, or Over or Under Weight?*
  • 5. Are they enrolled in a Health Home? (A New York State Health Home is a Medicaid care management program designed for people with complex medical, behavioral health, or social service needs.)*
  • 6. Do they have any medications that require refrigeration?*
  • 7. (Women only) Are they pregnant or postpartum?*
  • *
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 8. Are they currently receiving home-delivered meals or food services through a New York State (NYS) social services program? (e.g. Meals on Wheels, home-delivered meals for seniors, or other food assistance programs offered by NYS)*
  • 9. Does the member have difficulty climbing stairs or bathing?*
  • 10. Do they require refrigeration for breastmilk?*

  • Food Allergies / Dietary Restrictions

  • Do they have food allergies*
  • Please list allergies:*
  • Do they have dietary restrictions?*
  • Please select all that apply:*
  • Add another household member*
  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 1. Do they need assistance finding or keeping work or a job?*
  • 2. Do they have any chronic illnesses or conditions (ex: diabetes, asthma)?*
  • 3. Are there any other known health issues they may have?*
  • 4. Does this person suffer from Substance Use Disorders, Severe Mental Illnesses, Intellectual or Developmental Disabilities, or Over or Under Weight?*
  • 5. Are they enrolled in a Health Home? (A New York State Health Home is a Medicaid care management program designed for people with complex medical, behavioral health, or social service needs.)*
  • 6. Do they have any medications that require refrigeration?*
  • 7. (Women only) Are they pregnant or postpartum?*
  • *
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 8. Are they currently receiving home-delivered meals or food services through a New York State (NYS) social services program? (e.g. Meals on Wheels, home-delivered meals for seniors, or other food assistance programs offered by NYS)*
  • 9. Does the member have difficulty climbing stairs or bathing?*
  • 10. Do they require refrigeration for breastmilk?*

  • Food Allergies / Dietary Restrictions

  • Do they have food allergies*
  • Please list allergies:*
  • Do they have dietary restrictions?*
  • Please select all that apply:*
  • Add another household member*
  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 1. Do they need assistance finding or keeping work or a job?*
  • 2. Do they have any chronic illnesses or conditions (ex: diabetes, asthma)?*
  • 3. Are there any other known health issues they may have?*
  • 4. Does this person suffer from Substance Use Disorders, Severe Mental Illnesses, Intellectual or Developmental Disabilities, or Over or Under Weight?*
  • 5. Are they enrolled in a Health Home? (A New York State Health Home is a Medicaid care management program designed for people with complex medical, behavioral health, or social service needs.)*
  • 6. Do they have any medications that require refrigeration?*
  • 7. (Women only) Are they pregnant or postpartum?*
  • *
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 8. Are they currently receiving home-delivered meals or food services through a New York State (NYS) social services program? (e.g. Meals on Wheels, home-delivered meals for seniors, or other food assistance programs offered by NYS)*
  • 9. Does the member have difficulty climbing stairs or bathing?*
  • 10. Do they require refrigeration for breastmilk?*

  • Food Allergies / Dietary Restrictions

  • Do they have food allergies*
  • Please list allergies:*
  • Do they have dietary restrictions?*
  • Please select all that apply:*
  • Add another household member*
  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 1. Do they need assistance finding or keeping work or a job?*
  • 2. Do they have any chronic illnesses or conditions (ex: diabetes, asthma)?*
  • 3. Are there any other known health issues they may have?*
  • 4. Does this person suffer from Substance Use Disorders, Severe Mental Illnesses, Intellectual or Developmental Disabilities, or Over or Under Weight?*
  • 5. Are they enrolled in a Health Home? (A New York State Health Home is a Medicaid care management program designed for people with complex medical, behavioral health, or social service needs.)*
  • 6. Do they have any medications that require refrigeration?*
  • 7. (Women only) Are they pregnant or postpartum?*
  • *
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 8. Are they currently receiving home-delivered meals or food services through a New York State (NYS) social services program? (e.g. Meals on Wheels, home-delivered meals for seniors, or other food assistance programs offered by NYS)*
  • 9. Does the member have difficulty climbing stairs or bathing?*
  • 10. Do they require refrigeration for breastmilk?*

  • Food Allergies / Dietary Restrictions

  • Do they have food allergies*
  • Please list allergies:*
  • Do they have dietary restrictions?*
  • Please select all that apply:*
  • Add another household member*
  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 1. Do they need assistance finding or keeping work or a job?*
  • 2. Do they have any chronic illnesses or conditions (ex: diabetes, asthma)?*
  • 3. Are there any other known health issues they may have?*
  • 4. Does this person suffer from Substance Use Disorders, Severe Mental Illnesses, Intellectual or Developmental Disabilities, or Over or Under Weight?*
  • 5. Are they enrolled in a Health Home? (A New York State Health Home is a Medicaid care management program designed for people with complex medical, behavioral health, or social service needs.)*
  • 6. Do they have any medications that require refrigeration?*
  • 7. (Women only) Are they pregnant or postpartum?*
  • *
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 8. Are they currently receiving home-delivered meals or food services through a New York State (NYS) social services program? (e.g. Meals on Wheels, home-delivered meals for seniors, or other food assistance programs offered by NYS)*
  • 9. Does the member have difficulty climbing stairs or bathing?*
  • 10. Do they require refrigeration for breastmilk?*

  • Food Allergies / Dietary Restrictions

  • Do they have food allergies*
  • Please list allergies:*
  • Do they have dietary restrictions?*
  • Please select all that apply:*
  • Add another household member*
  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 1. Do they need assistance finding or keeping work or a job?*
  • 2. Do they have any chronic illnesses or conditions (ex: diabetes, asthma)?*
  • 3. Are there any other known health issues they may have?*
  • 4. Does this person suffer from Substance Use Disorders, Severe Mental Illnesses, Intellectual or Developmental Disabilities, or Over or Under Weight?*
  • 5. Are they enrolled in a Health Home? (A New York State Health Home is a Medicaid care management program designed for people with complex medical, behavioral health, or social service needs.)*
  • 6. Do they have any medications that require refrigeration?*
  • 7. (Women only) Are they pregnant or postpartum?*
  • *
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 8. Are they currently receiving home-delivered meals or food services through a New York State (NYS) social services program? (e.g. Meals on Wheels, home-delivered meals for seniors, or other food assistance programs offered by NYS)*
  • 9. Does the member have difficulty climbing stairs or bathing?*
  • 10. Do they require refrigeration for breastmilk?*

  • Food Allergies / Dietary Restrictions

  • Do they have food allergies*
  • Please list allergies:*
  • Do they have dietary restrictions?*
  • Please select all that apply:*
  • Add another household member*
  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 1. Do they need assistance finding or keeping work or a job?*
  • 2. Do they have any chronic illnesses or conditions (ex: diabetes, asthma)?*
  • 3. Are there any other known health issues they may have?*
  • 4. Does this person suffer from Substance Use Disorders, Severe Mental Illnesses, Intellectual or Developmental Disabilities, or Over or Under Weight?*
  • 5. Are they enrolled in a Health Home? (A New York State Health Home is a Medicaid care management program designed for people with complex medical, behavioral health, or social service needs.)*
  • 6. Do they have any medications that require refrigeration?*
  • 7. (Women only) Are they pregnant or postpartum?*
  • *
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 8. Are they currently receiving home-delivered meals or food services through a New York State (NYS) social services program? (e.g. Meals on Wheels, home-delivered meals for seniors, or other food assistance programs offered by NYS)*
  • 9. Does the member have difficulty climbing stairs or bathing?*
  • 10. Do they require refrigeration for breastmilk?*

  • Food Allergies / Dietary Restrictions

  • Do they have food allergies*
  • Please list allergies:*
  • Do they have dietary restrictions?*
  • Please select all that apply:*

  • DONE

  • Should be Empty: