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Needs Survey
Please answer the following questions to help us know how to best assist you and to help us recognize when our assistance has improved your situation.
14
Questions
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1
Name
*
This field is required.
First Name
Last Name
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2
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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3
What county do you live in?
Carbon County Wyoming
Crook County Wyoming
Goshen County Wyoming
Niobrara County Wyoming
Washakie County Wyoming
Weston County Wyoming
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4
Phone Number
*
This field is required.
Area Code
Phone Number
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5
Email
*
This field is required.
example@example.com
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6
Housing
*
This field is required.
Please choose the option that best fits your current housing.
I am homeless
I have an eviction notice
My housing costs are more than 30% of my income and I struggle to afford it.
My housing costs are more than 30% of my income but I can afford it most of the time.
My housing costs are ok because my rent is based on my income.
My housing costs are ok because the costs are less than 30% of my income.
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7
Food
*
This field is required.
Please choose the option that best fits your current food situation.
I have no food and no way to fix it.
I have no food and I am not on SNAP.
I am on SNAP but it isn't enough
I occasionally use food pantries
I am able to buy cheap food without help.
I can buy the food I want without help.
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8
Transportation
*
This field is required.
Please choose the option that best fits your current transportation situation.
I have no access to a car or public transportation.
I have access to transportation, but I can't depend on it.
I have access to transportation, but I can't afford it.
I have access to transportation but it isn't reliable.
I have access to transportation, but it could be better.
I have access to affordable and convenient transportation.
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9
Employment
*
This field is required.
Please choose the option that best fits your employment situation.
Not Applicable (I am unable to work. Retired/disabled)
I do not have a job and no unemployment.
I do not have a job, but I am on unemployment.
I work part time or seasonally.
I have a full time job but the pay is too low.
I have a full time job that pays ok but only has some or no benefits.
I have a full time time that has good pay and benefits.
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10
Income
*
This field is required.
Please choose the option that best fits your income situation.
I have no income.
My Income isn't enough to pay for my housing.
My income isn't enough to pay all of my bills.
My income usually covers my bills but sometimes I need help.
My income covers most bills without help.
My income is sufficient and I can save for the future.
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11
Credit
*
This field is required.
Please choose the option that best fits your credit situation
I have a bankruptcy or foreclosure on my credit report.
I have debt that is in collections.
My credit is poor and I have a lot of debt.
My credit is poor, but I don't have a lot of debt right now.
My credit is good, but I have a lot of debt.
My credit is good and I have little to no debt.
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12
Healthcare
*
This field is required.
Please choose the option that best fits your healthcare situation.
I have no insurance and have an immediate medical need.
I have no insurance and I have health issues that need to be addressed.
I have no insurance but no current health issues.
I have no insurance, but I can pay for the care I need for the moment.
I have some insurance but it doesn't cover everything.
I have adequate insurance and I have access to healthcare.
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13
Education
*
This field is required.
Please choose the option that best first your Education situation.
I did not complete the 10th grade in school.
I have no diploma or GED
I am enrolled in a GED program.
I have a High School Diploma or GED.
I have a High School Diploma/GED and some additional training or college.
I have either an Associates Degree or a College Degree.
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14
Network Support
*
This field is required.
Please choose the best option that fits the supports you currently have.
I have no family or friends to help me.
My family or friends could help, but refuse to help.
My family or friends are unable to help me.
I get some help from friends or family.
My family or friends help me if I need it.
My family or friends are always available to help.
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