Email *
Medicaid ID *
Birth Date: Please use the format 00/00/0000 *
Preferred Written Languages Arabic Bengali Chinese (Mandarin) Chinese (Yue) English French German Hindi Japanese Korean Marathi Nigerian Pidgin Portuguese Russian Spanish Tamil Telugu Turkish Urdu Vietnamese
Preferred Spoken Languages (copy) Arabic Bengali Chinese (Mandarin) Chinese (Yue) English French German Hindi Japanese Korean Marathi Nigerian Pidgin Portuguese Russian Spanish Tamil Telugu Turkish Urdu Vietnamese
Phone *
Address Type * — Select Choice — Home Mailing Unknown Work
buy a place
What is your living situation today? 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 do not have a steady place to live.
In the past 12 months, has the gas, water, oil, or electric company threatened to shut off services to your home? Yes No Already shut off
In the past 12 months, you worried your food would run out before you had money to buy more? Often true Sometimes true Never True
In the past 12 months, did lack of transportation keep you from work, meetings, medical appointments, or getting things needed for daily living? Yes No
Do you want help finding or keeping work or a job? Yes, help finding work Yes, help keeping work I do not want or need 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. Yes No
How often does anyone, including family and friends, physically hurt you? Never Rarely Sometimes Fairly Often Frequently Never Asked Declined to Answer
How often does anyone, including family and friends, insult or talk down to you? Never Rarely Sometimes Fairly Often Frequently Never Asked Declined to Answer
How often does anyone, including family and friends, threaten you with harm? Never Rarely Sometimes Fairly Often Frequently Never Asked Declined to Answer
How often does anyone, including family and friends, scream or curse at you? Never Rarely Sometimes Fairly Often Frequently Never Asked Declined to Answer
Does the Member have serious difficulty walking or climbing stairs (5 years old or older)? Yes No Asked, but declined
Does the Member have difficulty dressing or bathing (5 years old or older)? Yes No Asked, but declined
Is the client interested in receiving support for identified unmet Health Related Social Needs (HRSN)? Yes No
Which language was the screening completed in? Arabic Bengali Chinese (Mandarin) Chinese (Yue) English French German Hindi Japanese Korean Marathi Nigerian Pidgin Portuguese Russian Spanish Tamil Telugu Turkish Urdu Vietnamese
Was an interpreter used? Yes No
Who responded to the screening? Client/Member Parent/Guardian Spouse Caretaker Other Family Member/Friend
Screening modality In Person Phone Online
