Life Needs Assessment
Welcome to the Powerful Voices App Survey! By completing this form you are participating in a life needs assessment that can help us match needs with organizations in your community that provide resources and services that can help to address them. All personal contact information is protected by our privacy terms and conditions. We may reach out to you if we find a match.

Any questions or concerns please contact info@powerfulvoicesapp.com
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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 full 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?
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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?
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5. Do you have clothes that are okay for work, school, and for the local weather?
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6. Do you have enough money to meet your needs and pay bills on time?
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7. Do you have public or private health insurance for you and your family?
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8. Do you know how to get help if someone in your family needs mental or emotional health care?
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9. Do your family members ever make you feel unsafe?
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10. Do you have access to good quality childcare if you need it?
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11. Do you know how to get legal help if you need it?
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12. Do you have the skills you need to get the kind of jobs you want?
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13. Do you have a high school diploma or an equivalency diploma (such as a GED)?
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14. Do you know how to get more education if you want it?
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15. Can you say that you had no problems with addiction in the last 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. What is your Race or Ethnicity?
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