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.
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* Required
What is the name of the organization where you are completing this form?
*
Powerful Voices App
What is your name?
Your answer
What is your Phone Number?
Your answer
What is your email address?
Your answer
What is your full address? (example: 431 E Fayette St Syracuse, NY 13202) - Do not add apartment numbers- Zip codes are needed!
Your answer
1. Do you have long-term housing that you can afford?
Yes
No
Clear selection
2. Do you feel safe?
Yes
No
Clear selection
3. Do you have enough food?
Yes
No
Clear selection
4. Do you have dependable and safe transportation when you need it?
Yes
No
Clear selection
5. Do you have clothes that are okay for work, school, and for the local weather?
Yes
No
Clear selection
6. Do you have enough money to meet your needs and pay bills on time?
Yes
No
Clear selection
7. Do you have public or private health insurance for you and your family?
Yes
No
Clear selection
8. Do you know how to get help if someone in your family needs mental or emotional health care?
Yes
No
Clear selection
9. Do your family members ever make you feel unsafe?
Yes
No
Clear selection
10. Do you have access to good quality childcare if you need it?
Yes
No
Clear selection
11. Do you know how to get legal help if you need it?
Yes
No
Clear selection
12. Do you have the skills you need to get the kind of jobs you want?
Yes
No
Clear selection
13. Do you have a high school diploma or an equivalency diploma (such as a GED)?
Yes
No
Clear selection
14. Do you know how to get more education if you want it?
Yes
No
Clear selection
15. Can you say that you had no problems with addiction in the last year?
Yes
No
Clear selection
16. Has your home or child been tested for lead?
Yes
No
Clear selection
17. Do you know how to get help if you or someone in your family has a learning need?
Yes
No
Clear selection
18. Do you save some money for future needs?
Yes
No
Clear selection
19. Do you have a stable full-time job?
Yes
No
Clear selection
20. What is your Race or Ethnicity?
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Native Hawaiian and Pacific Islander
White
Some Other Race
Clear selection
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