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1) Please rate from 1 to 5 your overall well being.

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2) How often do you feel uncomfortable or out of place because of your race, ethnicity, culture, language, sexual identity or income?

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3) Do you have people in your life that would help you in case of crisis or need?

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3b.) If yes, how many people do you have in your life that would help you in case of crisis or need?

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4) How often do you feel frustrated or angry?

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5) In times of frustration or anger, how do you manage it?

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6) Do you have a medical condition?

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6b.) If YES: Are you receiving medical treatment for it?

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* 7) Please select the sentence that best describes your current financial situation:

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8) Do you currently have a bank account?

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9) Have you ever borrowed money from a payday lender/auto title lender?

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10) How many hours per week do you usually spend working?

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11) Did you have more than one job over the last four months?

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11b.) If yes, how many?

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12) Please rate from 1-5 your concerns that within the next 2 months, you may not have stable housing, shelter, or a steady place to sleep at night.

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13) Have you lived in any type of temporary housing in the last 24 months (Select all that apply)?

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14) In general, how would you rate your mental health?

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15) When experiencing mental health issues, how do you manage them?

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16) How many servings of fresh vegetables or fresh fruit do you eat during the week?

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17) How often are you physically active? (Walk, run, do sports, work out, do yoga, dance, etc.)

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18) Do you have regular access to the internet?

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18b.) If yes, you have access through:

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19) In case you need any type of additional social support, what organizations or programs do you go to for assistance? (Select all that apply.)

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20) Rate from 1-5 how confident you are in your knowledge of the social services available to you.

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21) How often do you volunteer in your community?

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22) Do you know where and how to vote?

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22b.) If yes, when was the last time you voted?

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23) Rate from 1-5 how safe you feel walking in your neighborhood after dark?

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24) Is your health or safety at risk in the place you were staying last night?

If you feel you or someone is subject to an immediate risk of diminished or loss of health and/or safety, report these conditions/circumstances immediately to the local legal authorities. (i.e. Law Enforcement, Code Enforcement, etc.) National and Local resources are available at the bottom of this survey

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