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Personal Characteristics

1. Are you Hispanic or Latino?
2. Which race(s) are you? Check all that apply.
3. Have you been discharged from the armed forces of the United States?
4. What language are you comfortable speaking?

Family & Home

5. Do you currently live with family members?
6. What is your housing situation today?
7. Are you worried about losing your housing?

Money & Resources

9. What is the highest level of school that you have finished?
10. What is your current work situation?
11. What is your main insurance?
13. In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? Check all that apply.
14. Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? Check all that apply.
16. Stress is when someone feels tense, nervous, anxious, or can't sleep at night because their mind is troubled. How stressed are you?

Money & Resources

17. In the past year, have you spent more than 2 nights in a row in a jail, prison, or juvenile correctional facility?
18. Are you a refugee?
19. Do you feel physically and emotionally safe where you currently live?
20. In the past year, have you been afraid of your partner or ex-partner?
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