LAS Priorities Survey - Client

Please take a few minutes to answer some questions about legal problems you might have.

This survey will help Legal Aid decide what kinds of cases to take.

For some questions you may choose more than one answer.

Thank you for your help.

Question Title

* 1. What Tennessee county do you live in?

Anderson

Bedford

Campbell

Cannon

Cheatham

Claiborne

Clay

Coffee

Cumberland

Davidson

DeKalb

Dickson

Fentress

Franklin

Giles

Grundy

Hickman

Houston

Humphreys

Jackson

Lawrence

Lewis

Lincoln

Macon

Marshall

Maury

Montgomery

Moore

Morgan

Overton

Perry

Pickett

Putnam

Roane

Robertson

Rutherford

Scott

Smith

Stewart

Sumner

Trousdale

Union

Van Buren

Warren

Wayne

White

Williamson

Wilson

Other (please write below)

Question Title

* 2. Please check all that apply.

I am a veteran.

I have children under 18 in my home.

My income is low.

I am disabled.

I am age 60 or older

I have someone in my home who does not speak English well.

I have gotten help from Legal Aid.

I am retired.

I came to the U.S. from another county.

I need a job.

I have people over age 60 in my home.

Other (please write below)

Question Title

* 3. Please check one.

I own my own home.

I live in public or Section 8 housing.

I live in a place where I pay the whole rent.

I live with others and pay my own way.

I live with others and do not pay rent and/or my own way.

I am homeless.

I pay rent

Question Title

* 4. During the past year has anyone in your household had legal problems with (OK to check more than one)

Getting a doctor's services?

Paying medical bills?

TennCare?

Getting nursing home care?

Private health insurance?

Getting hospital services?

Getting home health care?

Getting or paying for medicine?

Getting mental health services?

Medicare?

Other health problem? (please write below)

Question Title

* 5. During the past year has anyone in your household had legal problems with (OK to check more than one)

Juvenile court?

Guardianship of a child or conservatorship for an adult who can't make decisions for themself?

Getting child support?

Grandparents' rights?

Getting a divorce or separation?

Divorce

Family violence / spouse abuse / other abuse my someone you know?

Adoption?

Child custody or visitation?

Name change?

Other family problem? (please write below)

Question Title

* 6. During the past year has anyone in your household had legal problems with (OK to check more than one)

Bills you can't pay?

Bill collectors?

Collecting money owed to you?

Getting credit?

Something wrong on your credit report?

Identity theft?

Unfair credit?

Check advance or title loan company?

Bankruptcy?

Getting ripped off?

Other money problem? (please write below)

Question Title

* 7. During the past year has anyone in your household had legal problems with (OK to check more than one)

Having utilities cut off by landlord?

Private landlord?

Unfair credit?

Unsafe or unhealthy rental property?

Being evicted or locked out without going to court?

Public or Section 8 housing?

Making mortgage payments?

Foreclosure?

Other housing problem? (please write below)

Question Title

* 8. During the past year has anyone in your household had legal problems with (OK to check more than one)

Social Security Disability benefits (SSDI)?

SNAP or Food Stamps?

Workers' Comp?

Wage claims

Income tax

Social Security Retirement benefits?

Unemployment benefits?

Supplemental Security Income (SSI)?

Veterans' benefits?

Other public benefits problem? (please write below)

Question Title

* 9. During the past year has anyone in your household had legal problems with (OK to check more than one)

Special education?

Immigration?

Wills?

Court costs?

School discipline?

Driver's or other license?

Income taxes?

Cleaning up criminal record?

Paying public school fees for supplies or field trips?

Any other problem not listed? (please write below)