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COMMUNITY NEEDS SURVEY

Please Select the answer that BEST reflects your family's need




 Please select the 3 most critical issues in your community



Demographic Information
 Please select the most accurate information as it applies to you
AGE:
 GENDER:
 RACE:
ETHNICITY:
 HOUSING:
 SOURCE OF FAMILY INCOME:
ANNUAL INCOME LEVELS:
 HEALTH INSURANCE:
 ARE YOU AN EXPECTING MOTHER:
ADULT EDUCATION LEVEL:
 FAMILY TYPE:
 IS ENGLISH A SECOND LANGUAGE:

HOW MANY?		    
People in the home:
 Children in the home:
 Children under 5 in the home:
Seniors(over 60) in the home:
 Disabled in the home :
 Retired in the home:

If you are in need of immediate assistance please provide your name and number where you can be reached below.
(Optional)
NAME:
 		  PHONE:


What county do you live in? MERCER SUMMERS MONROE OTHER

No
answer
Do not
need help
Need met
with help
Getting help but need more
Need help
right now

 EMPLOYMENT

 

 

 

 

 

Getting a job

  

 

 

 

 

Getting a better job that pays my bills

 

 

 

 

 

Learning how to find a job

 

 

 

 

 

Gaining skills or education to get a job

 

 

 

 

 
           

No
answer
Do not
need help
Need met
with help
Getting help but need more
Need help
right now

TRANSPORTATION

        

Securing safe and reliable transportation

 

 

 

 
           

No
answer
Do not
need help
Need met
with help
Getting help but need more
Need help
right now

 HEALTH

      

Getting health care when needed

 

 

 

 

 

Getting substance abuse assistance for self or family member

 

 

 

 

 

Getting counseling or mental health assistance

 

 

 

 

Affording prescriptions

 

 

 

Getting vision or dental care

 

 

 

 
           

No
answer
Do not
need help
Need met
with help
Getting help but need more
Need help
right now

 HOUSING

          

Getting affordable housing

 

 

 

 

Affording home repairs

 

 

 

 

Assistance in buying a home

 

 

 

 

 

Learning how to lower utility bills

 

 

 

 
           

No
answer
Do not
need help
Need met
with help
Getting help but need more
Need help
right now

  FAMILY SUPPORTS

          

Knowing how to raise happy and healthy children

 

 

 

 

Finding programs to health children and youth succeed

 

 

 

 

 

Having a safe place for children after school or in summer

 

 

 

 

 

Help senior citizen stay safe and independent

 

 

 
           

No
answer
Do not
need help
Need met
with help
Getting help but need more
Need help
right now

  EMERGENCY SERVICES

          

Keeping the utilities on

 

 

 

 

 

Paying rent or mortgage

 

 

 

 

 

Keeping self/family safe from abuse

 

 

 

 

Need emergency housing or shelter

 

 

 

Having enough food for family

 

 

 

 

 

Having basic household goods for family

 

 

 

 

 
           

No
answer
Do not
need help
Need met
with help
Getting help but need more
Need help
right now

  INCOME

          

Making and following a budget

 

 

 

 

Learning how to improve credit

 

 

 

 

 

Understanding how to apply for assistance

 

 

 

 

 

Preparing and filing taxes for free

 

 

 

 

 

Please list any other needs you or your family may have: