Social Determinants of Health are the life conditions that affect a person's health. These include where you live, work, learn, and grow. We collect this information to understand your needs and connect you with helpful resources.

MiSide is a Community Impact Network in Detroit. We offer services like mental health support, early childhood programs, homeownership help, job support, money education, and more. This form asks questions about everyday needs like housing, work, food, school, and finances. It takes about 5 to 10 minutes to complete.

Most questions are optional. The only required questions are the consent statement, your name, and contact information marked with a *. We ask for your contact information so MiSide staff can follow up and offer help if needed.

After you complete the form, a staff member will contact you within 5 business days to answer questions and help connect you to services. If we cannot provide a service directly, we will help find other resources.

This tool was derived from the Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool. CMS secured permissions from the original authors of the screening questions in the AHC HRSN Screening Tool to use, copy, modify, publish, and distribute the questions for the AHC Model and CMS use only. This table specifies the preferred citation and tracking process for each screening question in the AHC HRSN Screening Tool if the questions are used outside of CMS and the AHC Model.

Please review the MiSide Privacy Practices by following the link below:

• MiSide Privacy Practices (Privacy Notice is available in English and Spanish)

This tool was derived from the Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool. CMS secured permissions from the original authors of the screening questions in the AHC HRSN Screening Tool to use, copy, modify, publish, and distribute the questions for the AHC Model and CMS use only. This table specifies the preferred citation and tracking process for each screening question in the AHC HRSN Screening Tool if the questions are used outside of CMS and the AHC Model.

This tool was derived from the Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool. CMS secured permissions from the original authors of the screening questions in the AHC HRSN Screening Tool to use, copy, modify, publish, and distribute the questions for the AHC Model and CMS use only. This table specifies the preferred citation and tracking process for each screening question in the AHC HRSN Screening Tool if the questions are used outside of CMS and the AHC Model.

This tool was derived from the Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool. CMS secured permissions from the original authors of the screening questions in the AHC HRSN Screening Tool to use, copy, modify, publish, and distribute the questions for the AHC Model and CMS use only. This table specifies the preferred citation and tracking process for each screening question in the AHC HRSN Screening Tool if the questions are used outside of CMS and the AHC Model.

This tool was derived from the Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool. CMS secured permissions from the original authors of the screening questions in the AHC HRSN Screening Tool to use, copy, modify, publish, and distribute the questions for the AHC Model and CMS use only. This table specifies the preferred citation and tracking process for each screening question in the AHC HRSN Screening Tool if the questions are used outside of CMS and the AHC Model.

11. Over the past 2 weeks, how often have you been bothered by any of the following problems?

This tool was derived from the Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool. CMS secured permissions from the original authors of the screening questions in the AHC HRSN Screening Tool to use, copy, modify, publish, and distribute the questions for the AHC Model and CMS use only. This table specifies the preferred citation and tracking process for each screening question in the AHC HRSN Screening Tool if the questions are used outside of CMS and the AHC Model.

This tool was derived from the Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool. CMS secured permissions from the original authors of the screening questions in the AHC HRSN Screening Tool to use, copy, modify, publish, and distribute the questions for the AHC Model and CMS use only. This table specifies the preferred citation and tracking process for each screening question in the AHC HRSN Screening Tool if the questions are used outside of CMS and the AHC Model.

Please answer whether the statement below is OFTEN, SOMETIMES, or NEVER true for you and your household in the last 12 months.

This tool was derived from the Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool. CMS secured permissions from the original authors of the screening questions in the AHC HRSN Screening Tool to use, copy, modify, publish, and distribute the questions for the AHC Model and CMS use only. This table specifies the preferred citation and tracking process for each screening question in the AHC HRSN Screening Tool if the questions are used outside of CMS and the AHC Model.