Needs Survey

Date Survey Completed *

Total Number of Household Members *

Number of FEMALES in the Household *

Number of MALES in the Household *

Number of VETERANS in the Household *

Is Anyone in the Household Disabled? *

Yes No

Type of Dwelling You Live In: *

House Apartment Apartment Complex Manufactured/mobile Home

Do You: *

Own Rent

Are Utilities Included? *

Yes No

Rent/Mortgage Monthly Amount ( if none, please put N/A) *

What County Do You Live in? *

Jackson Vinton

Do You Live Within City Limits? *

Yes No

What Services are you in need of right now (in addition to the housing needs listed to the right)? Please describe: *

Do you currently have any specific housing needs to resolve (such as no water, septic system, heating system, roof repairs, electrical, plumbing, handicap/special needs, etc.)? Please describe: *

What Counseling Services are you interested in? (Check all that apply) *

Please list any barriers that may keep you from being able to attend counseling services, if any. *

Please include any other comments regarding your needs you want us to know about. *

Completing this portion is optional. However, if you would like us to contact you in regards to the needs you have listed you must provide your contact information.

Address *

Line 1

Line 2

City

State

Zip Code

Country

Can We Contact You Via Texting? *

Yes No

Please List the Best Way to Reach You. *

Best Time to Reach You (please check all that apply). *

Morning Afternoon Any

Primary Phone Number *

Cell Phone Number *

Please complete the following survey questions to help us to better understand your needs. If you do not want to include your name and/or contact information on this form, that is your option.

Completing this portion is optional. However, if you would like us to contact you in regards to the needs you have listed you must provide your contact information.

Please complete the following survey questions to help us to better understand your needs. If you do not want to include your name and/or contact information on this form, that is your option.

Completing this portion is optional. However, if you would like us to contact you in regards to the needs you have listed you must provide your contact information.

Jackson-Vinton Community Action, Inc.
118 S. New York Avenue
Wellston, Ohio 45692

PROVIDING SERVICES TO jACKSON AND Vinton cOUNTIES

Visit us on facebook

Hours

Telephone

Email Executive Director

﻿﻿﻿Please complete the following survey questions to help us to better understand your needs. If you do not want to include your name and/or contact information on this form, that is your option.﻿

Completing this portion is optional. However, if you would like us to contact you in regards to the needs you have listed you must provide your contact information.

﻿﻿﻿Please complete the following survey questions to help us to better understand your needs. If you do not want to include your name and/or contact information on this form, that is your option.﻿

Completing this portion is optional. However, if you would like us to contact you in regards to the needs you have listed you must provide your contact information.

Jackson-Vinton Community Action, Inc.118 S. New York AvenueWellston, Ohio 45692PROVIDING SERVICES TO jACKSON AND Vinton cOUNTIES Visit us on facebook

Hours

Telephone

Email Executive Director

Please complete the following survey questions to help us to better understand your needs. If you do not want to include your name and/or contact information on this form, that is your option.

Please complete the following survey questions to help us to better understand your needs. If you do not want to include your name and/or contact information on this form, that is your option.

Jackson-Vinton Community Action, Inc.
118 S. New York Avenue
Wellston, Ohio 45692

PROVIDING SERVICES TO jACKSON AND Vinton cOUNTIES

Visit us on facebook