Life Needs Assessment
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.
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What is the name of the organization where you are completing this form? *
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?
Clear selection
2. Do you feel safe?
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3. Do you have enough food?
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4. Do you have dependable and safe transportation when you need it?
Clear selection
5. Do you have clothes that are okay for work, school, and for the local weather?
Clear selection
6. Do you have enough money to meet your needs and pay bills on time?
Clear selection
7. Do you have public or private health insurance for you and your family?
Clear selection
8. Do you know how to get help if someone in your family needs mental or emotional health care?
Clear selection
9. Do you have any family members that make you feel unsafe?
Clear selection
10. Do you have access to good quality childcare if you need it?
Clear selection
11. Do you know how to get legal help if you need it?
Clear selection
12. Do you have the skills you need to get the kind of jobs you want?
Clear selection
13. Do you have a high school diploma or an equivalency diploma (such as a GED)?
Clear selection
14. Do you know how to get more education if you want it?
Clear selection
15. Can you say that no one in your household has struggled with addiction in the past year?
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16. Has your home or child been tested for lead?
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17. Do you know how to get help if you or someone in your family has a learning need?
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18. Do you save some money for future needs?
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19. Do you have a stable full-time job?
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20. Do you have sufficient internet and technology access to meet your needs for school, work, and other responsibilities?
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21. What is your Race or Ethnicity?
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22. What is your gender?
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23. What is your annual income?
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24. What is your age?
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25. Do you, or any members of your household, have a disability?
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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.
27.  And what are the 3 least pressing needs our community faces?
28.  How aware are you of what our local government is doing to respond to the needs of your community through services and projects?
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29.  How aware are you about what other organizations (not government) are doing to respond to the needs of your community?
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30.  How aware are you about decisions that are made by our local government?
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31.  How aware are you about how your local taxes are being spent?
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32.  How would you describe your ability to get the services you need from local government?
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33.  How aware are you about ways to get involved in your local community?
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34.  How would you describe the opportunities members of your community have to comment on local government decisions and projects?
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