Form Pub 428a - Client Needs Survey
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1Client Needs Survey
Please complete the following anonymous survey for the State Department of Social Services to
gather more information about how to help families and children. This information will be used to
provide more accessible services and resources to families and children.
Please enter your zip code___________________
1. Have you used public assistance in the last
5. How do you plan to use your tax refund?
year? If so, please check all the boxes that
Please check all the boxes that apply.
apply.
Save or place in a savings account
None
Pay credit card bills
Cash aid
Pay debt to a friend or family member
CalFresh
Pay rent or mortgage
Housing Assistance
Pay utility bill
MediCal
Pay child care
Women Infant Children (WIC)
Pay medical bills
Other (Please describe)
Recreation/Entertainment/Vacation
______________________________________
Pay to fix something
Make car payment
2. What is your current housing situation?
Other (Please describe)
______________________________________
Rent
Stay with family or friends
6. Which services would help reduce emotional or
Own
financial stress in your household? Please
Transitional Housing
check all the boxes that apply.
Homeless/Temporary Housing
Other (Please describe)
Basic Needs (clothing, diapers, etc)
______________________________________
Food Assistance
Housing Assistance
3. Do you use childcare? If yes, who takes care of
Health Care
your child or children? Check all that apply.
Dental Care
Child Care
I do not use child care
Parenting Classes
Family or friend of the family
Family Counseling
Child Care Center
Anger Management
After school program
Healthy Relationship Workshops
Mental Health Treatment
4. What is the highest education level you’ve
Transportation
completed?
Drug/Alcohol Abuse Treatment
Financial Counseling/Budgeting
Grade School
Employment Services
Not applicable
Job Training (resume, interview skills, etc.)
High School
Continuing Education
GED
Other (Please describe)
Some College
______________________________________
College Degree
Graduate School
Decline to Answer
PUB 428A (1/17)
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Parent category: Legal