HOME DELIVERED MEALS
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)
NAME:
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First Name
Last Name
MEDICAID CLIENT IDENTIFICATION # (CIN)
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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
FOOD:
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Please Select
I am *FOOD INSECURE*, in the last 12 months I was worried that food would run out before I got more money to buy more
I am *FOOD INSECURE*, in the last 12 months the food I bought didn't last, and I didn't have more money to buy more
I am food secure, I DO NOT need assistance
LIVING:
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Please Select
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 am home insecure staying: in a hotel, shelter, homeless, abandoned building, park, bus or train station
HOUSING:
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Please Select
No housing issues
Pest infestation
Mold
Lead paint
No heat
Oven/Stove not working
Smoke detectors not working
Water leaks
UTILITIES:
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Please Select
My utilities work fine
My utilities have been shut off
The electric, gas, oil, or water company has threatened to shut off services
TRANSPORTATION:
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Please Select
I have reliable transportation
In the past 12 months, I have lacked reliable transportation keeping me from medical appointments, meetings, work, or getting things needed for daily living
CAREER:
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Please Select
I DO NOT need help finding a job, or keeping my current job
Yes, I need help finding a job
Yes, I need help keeping my current job
SCHOOL:
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Please Select
I DO NOT need help with school or training
I need help with school or training. For example, starting or completing job training or getting a high school diploma or GED
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 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
PREFERRED PHONE NUMBER:
PREFERRED ADDRESS:
Should be Empty: