BCMW Community Action Agency

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* 1. What county do you live in?

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* 2. Are you aged 55 or over?

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* 3. Are you married or living or living with a partner?

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* 4. Employment (which employment needs could you use help with (select all that apply))

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* 5. Education (which education needs could you or a family member use help with)

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* 6. Financial and Legal issues (which financial and/or legal needs could you or your family use help with) select all that apply

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* 7. Food and Nutrition: Which food and nutrition needs could you or your family use help with (select all that apply)

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* 8. Parenting and Family Support (if you have children under the age of 18 living with you, which parenting and/or family support needs could you or your family use help with)? select all that apply.

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* 9. Transportation (which transportation needs could you or your family use help with) select all that apply

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* 10. Health (which health needs could you or a family member use help with) select all that apply

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* 11. Basic Needs (which basic needs could you or your family use help with) select all that apply

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* 12. Are there any problems  or needs that you or your family faced within the last 12 months that you were unable to get help with?

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* 13. How did you learn about BCMW?

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* 14. What are your sources of household income?

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* 15. What services has your household received from our agency within the last 12 months? Select all that apply

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* 16. Housing: Which housing needs could you or your family use help with (select all that apply)

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