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