How are you doing?


Please answer each question to help us better understand your needs.

Rate the affordability and reliability of your transportation. *



Rate the affordability and safety of your housing. *



Rate your ability to make your utility payments on time. *



Rate your ability to afford any medications you may have.



Rate your ability to see a doctor as needed. *



Rate your ability to afford a yearly eye exam. *



Rate your ability to see a dentist as needed. *



Rate your ability to obtain enough food. *



Your home require repairs to be safe. *




Please tell us what you would like us to know.
What is your name? (Leave blank if you wish to remain anonymous.)
Please enter date of completion: *

Please prove that you're not a Robot!

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