5 QUESTION HUMAN SERVICES SURVEY Question Title * 1. What town do you live in? Bedminster Bernards Bernardsville Bound Brook Branchburg Bridgewater Far Hills Franklin Green Brook Hillsborough Manville Millstone Montgomery North Plainfield Peapack/Gladstone Raritan Rocky Hill Somerville South Bound Brook Warren Watchung Outside Somerset County Question Title * 2. How do you get your income (Check all that apply) Social Security Food Stamps (SNAP) Temporary Aid for Needy Families Program (TANF) General Assistance Employment Other Question Title * 3. Which 1 group do you identify with the most? (Only check one) Children, Youth, and Families Mental health Substance abuse Low income Homeless Developmentally disabled Physically disabled Elderly Question Title * 4. Please choose the 6 issues that affect you the most. (Required.) HIV/AIDS related Blind/visual impairment Police record Dental health Youth court record Mental health issues Developmental disability Discharge from corrections Divorce/separation Domestic violence Economic stress Learning disability Family/child conflict Homeless (no permanent housing) Not enough local doctors take my insurance Lack of affordable/quality child care Lack of dependent care Lack of employment/skills/education Lack of affordable housing Lack of independent living skills Lack of parenting skills Lack of legal services Lack of protective services Lack of health insurance Forced labor Senior abuse Child abuse Marital troubles Physical health problems Co-occurring disorder (mental health and substance abuse) Pregnancy/teen parenting Runaway Sexual abuse Sexual identity (LGBTQ) concerns Substance abuse Youth in transitional housing/shelter Lack of transportation School problems Other (please specify) Question Title * 5. Which groups do you identify with? (Check all that apply) Children, youth, and families Mental health Substance abuse Low income Homeless Developmentally disabled Physically disabled Elderly Done