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* 1. Do you currently receive assistance with any of the following? (Please select all applicable fields)

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* 2. Do you have a need for assistance with any of the following resources? (Please select all applicable fields)

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* 3. Below is a list of agencies. Please select any who are providing you and your family with help?

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* 4. How have you currently learned about resources?

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* 5. How would you most like to receive additional information regarding social services?

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* 6. What is your employment status?

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* 7. Are you able to work?

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* 8. If unemployed, are you currently looking for work?

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* 9. Would you like help with these job-related activities? (Check all that apply)

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* 10. Do you have reliable telephone access?

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* 11. Do you have access to the Internet?

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* 12. Where do you usually use the internet? (Check all that apply)

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* 13. What is your housing status?

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* 14. Please select your age range.

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* 15. What is your race or ethnicity?

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* 16. What is your highest level of education?

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* 17. If you want additional assistance, please share your name and contact information with us.  The Social Service Coordinator, Tavion Bozeman, will be in touch within a week of your response.

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