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