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United for San Diego Information and Basic Needs Assessment
Please complete the following form. It should take approximately 3-5 minutes to complete. Your responses help us understand your needs and connect you with available resources. All information is confidential.
Referring Agency
*
Demographics
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Gender
Male
Female
Other
Prefer not to answer
Race/Ethnicity (Select all that apply)
African/African American/Black
Asian
Pacific Islander
American Indian/Alaskan Native
Hispanic/Latino
White/Caucasian
Other
Unknown
Prefer not to answer
Primary Language spoken at home
Address
Zip Code
Phone Number
Email Address
What is the best way to contact you? (Select all that apply)
Email
Phone
Text
Household Size
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten or more
Prefer Not to Answer
Household Type
Single Adult NO Child(ren)
Single Adult with Child(ren)
Two Adults NO Child(ren)
Two Adults and Child(ren)
Multigenerational
Other
Annual Household Income (Before Taxes)
$0-$9,999
$10,000-$19,999
$20,000-$29,999
$30,000-$39,999
$40,000-$49,999
$50,000-$59,999
$60,000-$74,999
$75,000-$99,999
$100,000 or more
Prefer Not to Answer
Types of Non-Cash Benefits (Select all that apply)
SNAP(CalFresh)
WIC
LIHEAP
Housing Choice Voucher
Public Housing
Permanent Supportive Housing
HUD-VASH
Childcare Voucher
Affordable Care Act Subsidy
Other
Prefer Not to Answer
None
Military Status
Active Duty
Veteran
Never Served in Military
Prefer Not to Answer
Housing Type
Own
Rent
Unhoused/Homeless
Other
Prefer Not to Answer
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Basic Needs Screener
This screening tool helps us understand your current needs and stability. Please answer the following questions honestly. Your responses may help us connect you to resources and support.
Do you currently live in a shelter or have no steady place to sleep at night?
Yes
No
Are you worried about losing your housing in the next two months?
Yes
No
In the past 30 days, have you worried about running out of food for your family?
Yes
No
In the past 30 days, did the food you bought not last and you did not have money to buy more?
Yes
No
Do you have enough money to meet your basic monthly expenses (rent, food, utilities, transportation, childcare)?
Yes
No
Are you currently enrolled in all public benefits you believe you qualify for (CalFresh, Medi-Cal, CalWorks, WIC, etc)?
Yes
No
Unsure
Do you have someone you can count on for support in an emergency situation?
Yes
No
When new needs come up, do you know where to go for help?
Yes
No
Would you like help connecting to resources? (Select all that apply)
Housing/Shelter
Food
Income/Utilities
Community
Resources
None
Submit
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