Client Needs Assessment

Living Situation:
Rent/Own Home
Homeless
Car
Staying with friend/family

Gender:
Male
Female

Race/Ethnicity:
White
Black
Asian/Pacific Islander
Native American

Hispanic:
Yes
No

Age:
18-25
26-35
36-45
46-55
55+

How many times have you experienced homelessness?
0
1
2
3
4+

Select the services you need but don't have.  Please not we cannot provide all of the services listed, but we should be able to provide referrals to services.
 

Basic Necessities:
Food
Clothing
Housing
Hygiene Products (e.g., soap, etc.)

Health and Mental Health Services:
Medications
Mental Health Counseling
Drug/Alcohol Counseling
Health Insurance
Dental Care
Vision Care

Legal Needs:
Legal Help
ID/Social Security Card

Other Needs:
Childcare
Transportation
Domestic Violence
English as Second Language Services
Employment

Other Needs:
 

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What keeps you from getting the services you need?
 

  • 50 characters left.