PCC Intake 2017
Do you have any immediate needs?
Food/water
Counseling Services
Medical Attention
Other
Other
Please Specify:
How many members of your household are here at PCC?
1
2
3
4
5
6
Other
Please Specify:
Have you been to Scott Carver PCC before?
Yes
No
County of residence?
Carver
Scott
Other
Other
Please Specify:
Would you like to use our childcare services?
Yes
No
Do you have children between the ages of 3 and 5?
Yes
No
If so, has your local school district provided your child/children with pre-school screening?
Yes
No
If no, why not?
Don't know what district I live in
Don't know where I will be living when my child is in Kindergarten
Don't know what pre-school screening is
Don't want my child screened
Other
Head of household race/ethnicity
African American
American Indian
Asian/SE Asian Pacific Islander
Hispanic/Chicano/ Latino
White/Caucasian
Multiracial
Race Unknown
Other
Prefer not to answer
Head of household education level
No diploma
High school/GED
Some college
Technical college
4-yr college degree
Masters/Doctorate
Head of household employment status
Employed full time
Employed part time
Seasonally employed
Homemaker
Student
Unemployed
Disabled
Retired
Other
Other
Please Specify:
Household annual income
$0-$9,999
$10,000-$24,999
$25,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000 and above
Where did you stay last night?
Rental House/apartment
Foster care or group home
Medical hospital
House/condo/apartment that you own
Living with family or friends
Psychiatric hospital or facility
Subsidized rental housing
Car or other vehicle
Substance abuse treatment center (including detox)
Hotel/motel (without voucher)
Shelter or hotel with voucher
Jail, prison, or juvenile facility
Permanent housing for formerly homeless
On the street or outside (camping)
Don't know/refuse to answer
Transitional housing for homeless
Outbuilding/abandoned building
Other
Other
Please Specify:
How long have you stayed there?
1 week or less
More than 1 week but less than 1 month
1-3 months
More than 3 months but less than 1 year
1 year or longer
If currently homeless, how long have you been homeless?
First time homeless AND less than 1 year without home
Several times homeless, but for less than 1 year and NOT more than 4 times in 3 years
Long term: at least 1 year OR at least 4 times in the past 3 years
Do you have your own vehicle?
Yes
No
If you don't have your own vehicle, how do you get to where you need to go?
Family member
Friends
Walk
Public Transportation
Other
If you use public transportation, what percentage of the time do you use it?
1-25%
25-50%
50-75%
65-100%
What form of public transportation do you use?
Taxi or Uber
Bus route
Dial-a-ride or door to door bus service
What is your biggest concern about public transportation
It is too expensive
It does not have pick up or drop off times that are convenient for me
It does not have pick up or drop off locations that are convenient for me
I do not know how to use public transportation
I do not know what companies provide public transportation in my community
Other
Health related issues: Check all that apply
Unable to work due to medical issues/recent disability
Struggling financially due to healthcare expenses
In need of medical care
In need of dental care
In need of health insurance
No current healthcare or health insurance needs
Do you have any type of disability that keeps you from working, shopping, or other daily activities
Yes
No
Don't know
Declined
If yes, do you expect it to last for 1 year or more?
Yes
No
Don't know
Decline
PCC Services: What would you like help with today?
Medical Care
Children's Dental Care
Eye Care
Legal Assistance
Breast Cancer Screening
Car seat information
Health Insurance
Healthcare resources
Employment services
Education resources
Mental health services
Chemical health services
Domestic violence services
Free cell phone
Massage
Haircut
Housing/ Homeless services
Rent/Deposit Assistance
Public Assistance
Food support
Fuel/heat assistance
Social security benefits
Veterans benefits
Other
Other
Please Specify:
Would you like help getting a copy of a MN birth certificate
Yes
No
Would you like help getting MN picture ID
Yes
No
Would you like help getting a driver license or license renewal
Yes
No
Would you like help paying for GED tests
Yes
No
If experiencing homelessness, would you like to receive a pass to a local community center to use their showers?
Yes
No
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