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* Applicant/Main Contact

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* HOUSING. What is your housing situation today?

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* HOUSING. Think about the place you live. Do you have problems with any of the following? (check all that apply)

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* FOOD.  Within the past 12 months, you worried that your food would run out before you got money (or other benefits) to buy more.

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* UTILITIES. In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?

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* FINANCES. How often does this describe you? I don’t have enough money to pay my bills:

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* MENTAL HEALTH.  Over the past 2 weeks, how often have you been bothered by any of the following problems?

  Never Once or Twice Monthly  Weekly Daily or Almost Daily
Little interest or pleasure in doing things?
Feeling down, depressed or hopeless?

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* DISABILITIES.  Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

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* DISABILITIES.  Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?

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* What do you want help with?

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* Are you currently working with any organizations for help?  Please list.

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