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