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Welcome!
Thank you for taking the time to participate in the assessment for what our community needs! Estimate time- 3-5 mins.
10
Questions
START
1
1. What do you think are the TOP
3 to 5
needs impacting you and people in your community?
Child care
After-school/summer programs for youth
Employment Opportunities
Language Barriers
Training or education
Elder services
Affordable housing
Ability to pay heating or utility bills
Access to food
Health care
Mental health services
Addiction services
Domestic violence services
Public Safety
Transportation
Citizenship Issues
Ability to save
Access to legal services
Clothing & Basic Essentials
Financial emergencies
Immigration issues
Discrimination issues
Access to technology/internet
Behavioral Health
Disability Services
Veterans Services
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2
2. Did we miss anything? (Please add additional comments).
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3
3. What keeps you or your family from being more financially stable?
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4
4. Where do you live?
ZIP Code
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5
5. What is your age?
Under 18
18-24
25-44
45-64
65 and older
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6
6. What is your gender, as you define yourself?
Male
Female
Non-binary
Other
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7
7. Are you Hispanic/Latino?
Yes
No
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8
8. What is your Race? (Please check one)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian / Other Pacific Islander
White
Other
Multi-Race
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9
9. What is your household’s monthly income?
Do not include: Food Stamps (SNAP), WIC, MassHealth, Other Public Health Insurance, Fuel Assistance, etc.
Under $2000/month (or Under $24,000/year)
$2000 - $4000/month (or $24,000 - $48,000/year)
$4001 - $6000/month (or $48,001 - $72,000/year)
Over $6000/month (or Over $72,000/year)
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10
10. Contact Information
Please include your name, phone number, and email.
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