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* 1. Which location did you visit for assistance, if any?

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* 2. What is your zip code?

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* 3. Are any household members Disabled?

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* 4. Which best describes your current housing?

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* 5. What is the range of your monthly rent/mortgage payment?

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* 6. In general do you feel that you are financially 

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* 7. This section is about the entire household. Add additional household members on the back of this page.

  Age Race Sex Education Monthly Income Source of Income Health Insurance Veteran
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* 8. Was the most recent time your first time requesting services from Mobile Community Action?

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* 9. Does your household Receive SNAP/Food Stamp benefits?

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* 10. Do you have any dependents age 0-5 attending the Early Head Start or Head Start Program?

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* 11. Are you currently employed?

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* 12. If no, how long have you been unemployed?

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* 13. Are you currently in arrears on your housing (rent/mortgage) payment?

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* 14. Do you need consumer (credit/budget) counseling

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* 15. Do you need assistance with home repairs?

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* 16. Do you need assistance with your home heating/cooling costs?

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* 17. Do you have a General Education Diploma (GED) or high school diploma?

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* 18. If no, would you be interested in obtaining a GED?

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* 19. Do you need training or need to be retrained for a suitable job?

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* 20. What training do you seek?

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* 21. Do you usually have access to transportation?

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* 22. Please select all that apply to you.

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* 23. What do you feel may help you to reach your personal and/or professional goals?

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* 24. What services have you or your family received in the last twelve (12) months from any organization or agency (mark all that apply)?

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* 25. Please list two (2) personal goals that you hope to accomplish in the next 12 months.

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* 26. List five needs in your community.

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* 27. Are you interested in volunteer opportunities with this agency? (If yes, please print your name and contact information below.

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* 28. Include any comments here:

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