With you in mind.
NCCSocial Screening Tool

Accountable Health Communities (AHC) Screening Tool

The Office of Mental Health (OMH) has requested that providers implement the following assessment of the Social Determinants of Health for their clients. Providers can use the results from the AHC Screening Tool to inform patients’ treatment plans and make referrals to community services. This screening tool is designed to connect people to resources such as food, housing, transportation and more. Your response to these questions can help Neighborhood Counseling Center assist in meeting your needs. Please review and complete the following screening tool.

Thank you
Intake Department
Neighborhood Counseling Center

Social Needs Screening Tool

Housing Instability: What is your housing situation today?
Think about the place you live. Do you have problems with any of the following?
Food Insecurity: 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, has lack of transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?
Utility Needs: In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?
Financial Strain: How hard is it for you to pay for the very basics like food, housing, medical care, and heating? Would you say it is:
Employment: Do you currently have a job?
Do you want help finding or keeping work or a job?
Do you speak a language other than English at home?
Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, GED or equivalent.
Family and Community Support: If for any reason you need help with day-to-day activities such as bathing, preparing meals, shopping, managing finances, etc., do you get the help you need?
How often do you feel lonely or isolated from those around you?
Childcare: Do you have problems getting childcare when you need it?
Criminal Justice: Have you ever been under any form of community criminal justice supervision (prison, jail, probation, parole, or criminal court-based mandate)?
Discrimination: In the past year have you experienced discrimination based on your skin color, your accent, where you are from, gender, gender identity, sexual orientation, mental disorder, physical condition, substance use or any other reason?