LAS Priorities Survey - Client Please take a few minutes to answer some questions about legal problems you might have. This survey will help Legal Aid decide what kinds of cases to take. For some questions you may choose more than one answer. Thank you for your help. OK Question Title * 1. What Tennessee county do you live in? Anderson Bedford Campbell Cannon Cheatham Claiborne Clay Coffee Cumberland Davidson DeKalb Dickson Fentress Franklin Giles Grundy Hickman Houston Humphreys Jackson Lawrence Lewis Lincoln Macon Marshall Maury Montgomery Moore Morgan Overton Perry Pickett Putnam Roane Robertson Rutherford Scott Smith Stewart Sumner Trousdale Union Van Buren Warren Wayne White Williamson Wilson Other (please write below) OK Question Title * 2. Please check all that apply. I am retired. I have gotten help from Legal Aid. I am age 60 or older I came to the U.S. from another county. I am a veteran. I am disabled. I have children under 18 in my home. I have people over age 60 in my home. I have someone in my home who does not speak English well. My income is low. I need a job. Other (please write below) OK Question Title * 3. Please check one. I own my own home. I live in public or Section 8 housing. I live in a place where I pay the whole rent. I live with others and pay my own way. I live with others and do not pay rent and/or my own way. I am homeless. I pay rent OK Question Title * 4. During the past year has anyone in your household had legal problems with (OK to check more than one) Getting nursing home care? Paying medical bills? Getting a doctor's services? Medicare? TennCare? Private health insurance? Getting mental health services? Getting home health care? Getting hospital services? Getting or paying for medicine? Other health problem? (please write below) OK Question Title * 5. During the past year has anyone in your household had legal problems with (OK to check more than one) Getting child support? Child custody or visitation? Grandparents' rights? Family violence / spouse abuse / other abuse my someone you know? Name change? Juvenile court? Divorce Guardianship of a child or conservatorship for an adult who can't make decisions for themself? Adoption? Getting a divorce or separation? Other family problem? (please write below) OK Question Title * 6. During the past year has anyone in your household had legal problems with (OK to check more than one) Getting credit? Bills you can't pay? Collecting money owed to you? Something wrong on your credit report? Bankruptcy? Check advance or title loan company? Unfair credit? Identity theft? Bill collectors? Getting ripped off? Other money problem? (please write below) OK Question Title * 7. During the past year has anyone in your household had legal problems with (OK to check more than one) Unfair credit? Foreclosure? Private landlord? Unsafe or unhealthy rental property? Having utilities cut off by landlord? Being evicted or locked out without going to court? Public or Section 8 housing? Making mortgage payments? Other housing problem? (please write below) OK Question Title * 8. During the past year has anyone in your household had legal problems with (OK to check more than one) Income tax Unemployment benefits? Supplemental Security Income (SSI)? Workers' Comp? Social Security Disability benefits (SSDI)? Veterans' benefits? Wage claims SNAP or Food Stamps? Social Security Retirement benefits? Other public benefits problem? (please write below) OK Question Title * 9. During the past year has anyone in your household had legal problems with (OK to check more than one) School discipline? Cleaning up criminal record? Special education? Income taxes? Paying public school fees for supplies or field trips? Immigration? Wills? Driver's or other license? Court costs? Any other problem not listed? (please write below) OK DONE