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Cheyenne River Youth & Young Adult Housing Needs Survey
*
1.
Date
(Required.)
2.
Name (optional)
*
3.
Age
(Required.)
*
4.
Gender
(Required.)
Male
Female
Non-binary
*
5.
Community you are from
(Required.)
Current Housing Situation
6.
Which of the following best describes your current housing situation?
Living with relatives or extended family
Staying with friends (couch surfing)
Living in a shelter or housing program
Living in a vehicle, outdoors, or another temporary location
Other (please specify)
7.
Where did you stay last night?
Emergency shelter
Friends or family member’s home
Outdoors or on the street
Transitional housing
Other (please specify)
8.
Do you have children?
Yes
No
If Yes, how many children do you have?
Basic Needs & Safety
9.
Do you currently have access to basic necessities (clothing, hygiene products, personal care items, etc.)?
Yes
No
Sometimes
10.
In the past 30 days, have you worried about or experienced not having enough food to eat?
Never
Sometimes
Often
11.
Do you have any comments about question 10, please share (optional)
12.
Do you feel safe where you are currently staying?
Yes
No
Sometimes
13.
Do you have any comments about question 12, please share (optional)
Support System
14.
Do you have a trusted adult or support person you can talk to when you need help?
Yes
No
Service & Resources
15.
What services would be most helpful to you right now (Select all that apply)?
Housing assistance
Food assistance
GED preparation or educational support
Job training
Employment assistance
Mental health services
Education assistance
Other (please specify)
Additional Support Needs
16.
Have you ever experienced or are you currently experiencing exploitation, trafficking, or being forced to do things you do not want to do in exchange for money, shelter, food, transportation, or other necessities?
Yes
No
Prefer not to answer
17.
Do you have any comments about question 16, please share (optional)
