What is your living situation today?

Think about the place you live. Do you have problems with
any of the following? CHOOSE ALL THAT APPLY

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

Within the past 12 months, you worried that your food
would run out before you got money to buy more.

Within the past 12 months, the food you bought just didn't
last and you didn't have money to get more.^*

In the past 12 months, has lack of reliable transportation
kept you from medical appointments, meetings, work or from
getting things needed for daily living?

Do you want help finding or keeping work or a job?

Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, GED or equivalent

How often does anyone, including family and friends, physically hurt you?

How often does anyone, including family and friends, insult or talk down to you?

How often does anyone, including family and friends, threaten you with harm?

How often does anyone, including family and friends, scream or curse at you?