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 disabled. I have gotten help from Legal Aid. I have people over age 60 in my home. I am retired. I am a veteran. My income is low. I am age 60 or older I need a job. I have someone in my home who does not speak English well. I came to the U.S. from another county. I have children under 18 in my home. 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) TennCare? Getting hospital services? Getting nursing home care? Getting home health care? Getting a doctor's services? Getting or paying for medicine? Getting mental health services? Medicare? Private health insurance? Paying medical bills? 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) Child custody or visitation? Name change? Adoption? Grandparents' rights? Family violence / spouse abuse / other abuse my someone you know? Getting a divorce or separation? Getting child support? Juvenile court? Divorce Guardianship of a child or conservatorship for an adult who can't make decisions for themself? 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) Identity theft? Bankruptcy? Getting credit? Bill collectors? Getting ripped off? Check advance or title loan company? Something wrong on your credit report? Unfair credit? Collecting money owed to you? Bills you can't pay? 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) Public or Section 8 housing? Unsafe or unhealthy rental property? Unfair credit? Having utilities cut off by landlord? Private landlord? Being evicted or locked out without going to court? Making mortgage payments? Foreclosure? 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) Supplemental Security Income (SSI)? Workers' Comp? Unemployment benefits? Veterans' benefits? Social Security Disability benefits (SSDI)? Income tax SNAP or Food Stamps? Social Security Retirement benefits? Wage claims 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) Court costs? Wills? Special education? Income taxes? Immigration? Paying public school fees for supplies or field trips? School discipline? Driver's or other license? Cleaning up criminal record? Any other problem not listed? (please write below) OK DONE