On a scale of 1 to 5, how concerned are you about:
The cost of Rent/Mortgage
Not concerned
Very concerned
Clear selection
Foreclosure
Not concerned
Very concerned
Clear selection
Threat of Eviction or Displacement
Not concerned
Very concerned
Clear selection
Homelessness
Not concerned
Very concerned
Clear selection
Bad conditions in your home
Not concerned
Very concerned
Clear selection
Vacant Land/Buildings
Not concerned
Very concerned
Clear selection
Lack of Affordable Housing
Not concerned
Very concerned
Clear selection
Lack of Employment
Not concerned
Very concerned
Clear selection
Neighborhood/Home Safety
Not concerned
Very concerned
Clear selection
Safe Community Space
Not concerned
Very concerned
Clear selection
Are you currently facing:
Check all applicable
Please give us some details:
Your answer
Do you know your legal housing rights?
What other issues in your community are you most concerned about?
Your answer
If you could change anything in your community what would it be?
Your answer
If you had the power to decide what type of development happens in your neighborhood, what would you do? (i.e. parks, school affordable housing, etc...)
Your answer
Race/Ethnicity:
Your answer
Gender:
Your answer
Age:
Your answer
Citizenship:
Your answer
Sexuality:
Your answer
City you live in:
Your answer
City/Town/Country of Origin:
Your answer
--OPTIONAL--
Name:
Your answer
Phone Number:
Your answer
Email
Your answer
Address:
Your answer
Would you be interested in getting involved with Springfield No One Leaves/learning more? *
Would you be willing to participate in a focus group discussion on housing and income issues? *
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This form was created inside of Springfield No One Leaves Coalition.