Life Needs Assessment

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By completing this form you are participating in a life needs assessment that will help us match your needs with organizations that provide services that can help to address them. We may reach out to you if we find a match. You must identify the organization where you are completing the form, but all other questions are optional.

What is the name of the organization where you are completing this form? *

FOCUS Greater Syracuse

What is your name?

What is your Phone Number?

What is your email address?

What is your address? (example: 431 E Fayette St Syracuse, NY 13202) - Do not add apartment numbers- Zip codes are needed!

1. Do you have long-term housing that you can afford?

Yes

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2. Do you feel safe?

Yes

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3. Do you have enough food?

Yes

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4. Do you have dependable and safe transportation when you need it?

Yes

Clear selection

5. Do you have clothes that are okay for work, school, and for the local weather?

Yes

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6. Do you have enough money to meet your needs and pay bills on time?

Yes

Clear selection

7. Do you have public or private health insurance for you and your family?

Yes

Clear selection

8. Do you know how to get help if someone in your family needs mental or emotional health care?

Yes

Clear selection

9. Do you have any family members that make you feel unsafe?

Yes

Clear selection

10. Do you have access to good quality childcare if you need it?

Yes

Clear selection

11. Do you know how to get legal help if you need it?

Yes

Clear selection

12. Do you have the skills you need to get the kind of jobs you want?

Yes

Clear selection

13. Do you have a high school diploma or an equivalency diploma (such as a GED)?

Yes

Clear selection

14. Do you know how to get more education if you want it?

Yes

Clear selection

15. Can you say that no one in your household has struggled with addiction in the past year?

Yes

Clear selection

16. Has your home or child been tested for lead?

Yes

Clear selection

17. Do you know how to get help if you or someone in your family has a learning need?

Yes

Clear selection

18. Do you save some money for future needs?

Yes

Clear selection

19. Do you have a stable full-time job?

Yes

Clear selection

20. Do you have sufficient internet and technology access to meet your needs for school, work, and other responsibilities?

Yes

Clear selection

21. What is your Race or Ethnicity?

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latinx

Middle Eastern or North African

Native Hawaiian and Pacific Islander

White

Some Other Race

22. What is your gender?

Female

Male

Nonbinary

Other

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23. What is your annual income?

$0-$15,000

$15,001-$30,000

$30,001-$45,000

$45,001-$60,000

$60,001-$75,000

$75,001-$90,000

More than $90,000

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24. What is your age?

18 or under

19-35

36-55

56 or over

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25. Do you, or any members of your household, have a disability?

Yes

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26. Now, please consider the needs of your community AS A WHOLE. What do you feel are their TOP 5 most important needs?

Please select 5 needs from the list below that you feel are the TOP 5 needs in the CNY community.

1. Have affordable housing options.

2. Feel safe in the community.

3. Have enough food.

4. Have dependable and safe transportation when needed.

5. Have clothes that are okay for work, school, and the local weather.

6. Have enough money to meet needs and pay bills on time.

7. Have public or private health insurance.

8. Know how to get help if someone needs mental or emotional health care.

9. Have family members that make he/she feel unsafe.

10. Have access to good quality childcare when needed.

11. Know how to get legal help if needed.

12. Have the skills needed to get the kind of jobs desired.

13. Have a high school diploma or equivalency diploma (such as a GED).

14. Know how to get more education if desired.

15. Have household members who have struggled with addiction in the past year.

16. Have had home or child tested for lead.

17. Know how to get help for a family who has a learning need.

18. Have some money saved up for future needs.

19. Have a stable, full-time job.

20. Have sufficient internet and technology access to meet needs for school, work, and other responsibilities.

27. And what are the 3 least pressing needs our community faces?

1. Have affordable housing options.

2. Feel safe in the community.

3. Have enough food.

4. Have dependable and safe transportation when needed.

5. Have clothes that are okay for work, school, and the local weather.

6. Have enough money to meet needs and pay bills on time.

7. Have public or private health insurance.

8. Know how to get help if someone needs mental or emotional health care.

9. Have family members that make he/she feel unsafe.

10. Have access to good quality childcare when needed.

11. Know how to get legal help if needed.

12. Have the skills needed to get the kind of jobs desired.

13. Have a high school diploma or equivalency diploma (such as a GED).

14. Know how to get more education if desired.

15. Have household members who have struggled with addiction in the past year.

16. Have had home or child tested for lead.

17. Know how to get help for a family who has a learning need.

18. Have some money saved up for future needs.

19. Have a stable, full-time job.

20. Have sufficient internet and technology access to meet needs for school, work, and other responsibilities.

28. How aware are you of what our local government is doing to respond to the needs of your community through services and projects?

1. Very aware

2. Somewhat aware

3. Neither aware nor unaware

4. Somewhat unaware

5. Not at all aware

Clear selection

29. How aware are you about what other organizations (not government) are doing to respond to the needs of your community?

1. Very aware

2. Somewhat aware

3. Neither aware nor unaware

4. Somewhat unaware

5. Not at all aware

Clear selection

30. How aware are you about decisions that are made by our local government?

1. Very aware

2. Somewhat aware

3. Neither aware nor unaware

4. Somewhat unaware

5. Not at all aware

Clear selection

31. How aware are you about how your local taxes are being spent?

1. Very aware

2. Somewhat aware

3. Neither aware nor unaware

4. Somewhat unaware

5. Not at all aware

Clear selection

32. How would you describe your ability to get the services you need from local government?

1. Excellent

2. Good

3. Neutral

4. Not Good

5. Poor

Clear selection

33. How aware are you about ways to get involved in your local community?

1. Very aware

2. Somewhat aware

3. Neither aware nor unaware

4. Somewhat unaware

5. Not at all aware

Clear selection

34. How would you describe the opportunities members of your community have to comment on local government decisions and projects?

1. Excellent

2. Good

3. Neutral

4. Not Good

5. Poor

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35. Do we have your permission to use the phone number that you provided to send you a text message with information about available services that you might find helpful?

If you do not want us to text you with this information, please select "No." If you would like to receive a text from us, please select your cellular carrier. (This information is required for us to automatically send you the text.) If your cellular carrier is not listed below, please select "No."

Yes -- Alltel

Yes -- AT&T

Yes -- Boost Mobile

Yes -- Cricket Wireless

Yes -- Google Fi Wireless

Yes -- MetroPCS

Yes -- Sprint

Yes -- T-Mobile

Yes -- U.S. Cellular

Yes -- Verizon

Yes -- Virgin Mobile

Yes -- XFinity Mobile

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