Have you contacted 2-1-1 before? *  (select one) No Yes Refused Did Not Ask

2-1-1 Referral Source *  (select one) 211 Cards/Posters Billboard Caller Does Not Remember DCA Mailing DCA Website Friend/Relative HEA Application Agency Internet Pharmacy Previous Knowledge Professional -- Agency Professional -- Healthcare Professional -- Police Professional -- Religious Professional -- School Radio/Pandora/Spotify Social Media -- Facebook Social Media -- Instagram Social Media -- Snapchat Social Media -- Twitter Television Transit Sign Utility Company YouTube Other Refused Did Not Ask

2-1-1 Referral Source - Other *

The following information about the individual in need will allow us to accurately refer to resources that can help.

Gender *  (select one) Male Female Transgender Other Prefer Not to State

Age *  (select one) 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76+ Prefer Not to State

Race *  (select one) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White or Caucasian Other Prefer Not to State

Ethnicity *  (select one) Hispanic or Latino Non-Hispanic or Latino Prefer Not to State

Disability Status *  (select one) Prefer Not to State Not Disabled Disabled

Disability Type *  (select one) Prefer Not to State N/A - not disabled Blindness Deafness / Hard of Hearing Deafblindness Other Physical Disability Intellectual Disability Traumatic Brain Injury Other

Military Status *  (select one) Never in the Military Active on Base Deployed Reserves Retired Veteran Veteran Prefer Not to State

Military Branch *  (select one) Not Applicable Air Force Army Marines Navy Air National Guard Coast Guard National Guard Prefer Not to State

What type of assistance do you need? *

The following questions about the individual in need and their household are optional, but may help us refer even more accurately.

Marital Status (select one) Civil Union Divorced Married Single Widowed Cohabiting Separated Prefer Not to State

Dependents (select one) No Dependents Child Dependents Adult Dependent(s) (age 18+) Child and Adult Dependent(s) Prefer Not to State

Housing (select one) Owns Home Renting School With Friends With Family Transitional Housing Homeless Prefer Not to State

Employment (select one) Two or More Incomes One Income - FT One Income - PT Self Employed Student Retirement Unemployment Prefer Not to State

Medical Insurance (select one) All Have Insurance Some Have Insurance None Have Insurance Prefer Not to State