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SURVEY <br />To try and serve you beaer. Aluneda Couury acid its service providers want to ask y~-u sonic questions about your <br />situation. We do not ask your name or anything that identifies who, you ace. . <br />Have you filled out this survey before? Yes No (if Yes, plra.r do trot fill out agaui.) <br />Are you: Female Mate <br />How old are you? Are you a veteran? Yes No <br />Are you disabled'? Yes No <br />If yes, what is your disability? ~'` <br />Physical Mental <br />HIV Substance Abuse <br />AIDS Other <br />Are you currently homeless? No ____ Yes <br />If yes, check your reason(s) wliy: <br />Escaputg domestic violence <br />Family break-up <br />Earthquake destroyed my home <br />Fire/other disaster destroyed my Home <br />Unable to pay rent <br />Evicted due to non-payment of rent <br />Discharged from art utstitutioti (please describe) <br />Couldn't maintain my income or stay housed <br />due to: <br />Job lost <br />Mental ilL~ess <br />Medical problems or medical costs <br />Alcohol or od~er drug use <br />Money management problems <br />Temporary IivinL situation ended <br />(Please explain) <br />Are you homeless with a spouse or life para~er? Yes <br />t{of Children with you seekutg services <br />l/of Children elsewhere <br />Iti what city did you attend: Eletnetttary school'?_ <br />College? <br />In die last six years, in what city/cities have you resided'? <br />In. what city did you most recently become homeless'?: <br />How long had you lived there? <br />How long have you been homeless? <br />How many tunes 1-ave you been ltotneless'? <br />No <br />Aczs t-f Children <br />Aces of Children <br />High School'?_ <br />