2021/2022 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 children under 18 in my home. I have gotten help from Legal Aid. I need a job. I am a veteran. I came to the U.S. from another county. I have someone in my home who does not speak English well. I am age 60 or older I have people over age 60 in my home. I am retired. My income is low. 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) Paying medical bills? Medicare? Getting hospital services? Private health insurance? Getting mental health services? Getting a doctor's services? TennCare? Getting or paying for medicine? Getting nursing home care? Getting home health care? 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) Juvenile court? Adoption? Guardianship of a child or conservatorship for an adult who can't make decisions for themself? Getting a divorce or separation? Grandparents' rights? Child custody or visitation? Family violence / spouse abuse / other abuse my someone you know? Getting child support? Name change? Divorce 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? Something wrong on your credit report? Bills you can't pay? Bankruptcy? Identity theft? Check advance or title loan company? Collecting money owed to you? Unfair credit? Getting ripped off? Bill collectors? 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) Having utilities cut off by landlord? Unfair credit? Private landlord? Being evicted or locked out without going to court? Public or Section 8 housing? Foreclosure? Making mortgage payments? Unsafe or unhealthy rental property? 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) Workers' Comp? Income tax Social Security Retirement benefits? Supplemental Security Income (SSI)? Veterans' benefits? SNAP or Food Stamps? Wage claims Unemployment benefits? Social Security Disability benefits (SSDI)? 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? School discipline? Special education? Wills? Cleaning up criminal record? Immigration? Paying public school fees for supplies or field trips? Driver's or other license? Any other problem not listed? (please write below) OK DONE