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100% of survey complete.

* 1. Today's Date:

Today's Date
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* 2. Share with us who you are

* 3. Who is your case-manager?

* 4. Are you the head of household?

* 5. How many children under the age of 18 live in your household?

* 6. What is your monthly rent payment?

* 7. What is your monthly income?

* 8. What is the monthly income of persons in your household 18 and over?

* 9. What benefits are you currently receiving?

* 10. Do you receive a utility allowance?

* 11. What is your Date of Birth?

* 12. What is the highest level of school you have completed or the highest degree you have received?

* 13. Which of the following categories best describes your employment status?

* 14. Are you currently enrolled as a student?

* 15. Are you currently enrolled in the Family Self-Sufficiency Program?

* 16. What is your reason for needing Referral Services?

* 17. Have your received referral support services in the past?

* 18. Reason for assistance or request?  PLEASE GIVE DETAILS!

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