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Student Needs Assessment
Form takes no more than 5 minutes.
Step
1
of
9
- Contact Information
11%
Name
(Required)
First
Last
Email
(Required)
Enter Email
Confirm Email
Student ID
(Required)
General Questions
Are you receiving any government assistance or support programs to help meet your basic needs?
(Required)
Yes
No
Are you aware of local community resources or organizations that can provide assistance with basic needs?
(Required)
Yes
No
Do you have a support network or access to social services that can help you in times of need?
(Required)
Yes
No
Are you currently employed or seeking employment to meet your basic needs?
(Required)
Yes
No
Basic Needs
Do you have access to reliable transportation to meet your basic needs (e.g., work, school, grocery shopping)?
(Required)
Yes
No
Do you have access to clean and safe drinking water?
(Required)
Yes
No
Are you able to afford basic hygiene products (e.g., soap, toothpaste, menstrual products)?
(Required)
Yes
No
Are you able to afford and maintain appropriate clothing for different seasons and occasions?
(Required)
Yes
No
Educational/Technology Needs
Do you have access to reliable and affordable internet and communication services?
(Required)
Yes
No
Are you able to afford necessary school supplies and materials?
(Required)
Yes
No
Food Needs
Are you able to consistently afford and access nutritious meals?
(Required)
Yes
No
Are you currently experiencing any financial hardships or difficulties meeting your basic needs?
(Required)
Yes
No
Have you ever had to sacrifice or forgo basic needs due to financial constraints?
(Required)
Yes
No
Housing & Utility Needs
Do you have a stable and safe place to live?
(Required)
Yes
No
Have you ever experienced homelessness or housing instability?
(Required)
Yes
No
Are you able to manage and afford your monthly rent or mortgage payments?
(Required)
Yes
No
Do you have access to affordable and reliable utilities (e.g., electricity, heating, cooling)?
(Required)
Yes
No
Medical Needs
Are you able to afford essential healthcare and medical expenses?
(Required)
Yes
No
Transportation Needs
Do you have access to reliable transportation to meet your basic needs (e.g., work, school, grocery shopping)?
(Required)
Yes
No
Other Service Needs
Do you have access to affordable and reliable childcare services if needed?
(Required)
Yes
No
Do you have any concerns or challenges regarding your basic needs that you would like to discuss or seek assistance with?
(Required)
Yes
No
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