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  • 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*.*

  • PERSONAL INFORMATION

  • DATE OF BIRTH:*
     - -
  •  -

  • SERVICES SCREENING

  • LIVING SITUATION

  • HAVE YOU HAD A MAJOR LIFE EVENT SINCE LAST SCREENING?*

  • WHAT IS YOUR LIVING SITUATION TODAY??*

  • HOUSING CONDITIONS

  • THINK ABOUT THE PLACE YOU LIVE. DO YOU HAVE PROBLEMS WITH ANY OF THE FOLLOWING?:*

  • UTILITIES

  • IN THE PAST 12 MONTHS HAS THE ELECTRIC, GAS, OIL, OR WATER COMPANY THREATENED TO SHUT OFF SERVICES IN YOUR HOME?:*

  • FOOD

  • WITHIN THE PAST 12 MONTHS, YOU WORRIED THAT YOUR FOOD WOULD RUN OUT BEFORE YOU GOT MONEY TO BUY MORE.*

  • TRANSPORTATION

  • IN THE PAST 12 MONTHS, I HAVE LACKED RELIABLE TRANSPORTATION TO MEDICAL APPOINTMENTS, MEETINGS, WORK, OR GETTING THINGS NEEDED FOR DAILY LIVING?:*

  • CAREER

  • DO YOU WANT HELP FINDING OR KEEPING WORK OR A JOB?:*

  • 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?*

  • NEXT STEPS & SIGNATURE

  • 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.

    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.

  • *VOLUNTARY* SAFETY QUESTIONS

    THE BELOW QUESTIONS ARE OPTIONAL AND DO NOT AFFECT ELIGIBILITY FOR SERVICES.
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