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* 1. What zip code do you live in?

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* 2. What service(s) did you apply for today?  (Check all that apply.)

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* 3. Please rate your level of satisfaction with the agency staff and services provided.

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* 4. Name one community concern that you would like our agency to address?

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* 5. In your opinion, does your community provide adequate assistance for lower income families and individuals in the categories below?  Please check Yes or No.

  Yes No
Child care
Energy/Utility Cost
Employment/Job Training
Financial literacy/planning
Housing
Education/HS Diploma/GED
Legal issues/services
Medical care/Prescriptions
Mental Health
Substance Abuse Treatment
Transportation

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* 6. Are you having difficulty obtaining a job that pays $15 per hour or more?

0 of 6 answered
 

T