Community Needs Questionnaire

Demographics and General Questions



Participant Demographics



















KCTCS and Kentucky State University Education

Student Information


KCTCS Student IDs are usually 9 digits and Kentucky State IDs are usually 8 digits. If your Student ID includes leading 0s or 1s, please include them.
Please keep in mind that if you receive a 2. Lookup error when submitting this form that this is due to the fact that the Student ID that you have entered here does not match any Student IDs currently on file in Salesforce.  
Contact Information

Providing your contact information will allow up to provide you with information if there are programs that are identified to be of assistance for you.




Understanding your current situation
















Income and Current Program Use

Income



Will help us identify programs that you may be eligible for. Please format as a currency (e.g 5.23). Other symbols, including -, will cause a form error upon submission due to not being in the format of a dollar amount



Current Program Use

Medicaid/Medicare



















Children and General 

Childcare









Children Information
Once you submit this form you will be redirected to an additional short form to enter the details and answer questions about the children.
Post Secondary Education

Please answer the questions below to help us understand your concerns and needs surrounding your social connections.




Referred
How did you come into contact with Family Scholar House? This information will help us prepare to serve additional people in the future!


Please Note: When you successfully submit this form you will be redirected to the Children Update form in order to Add or Update children records for this participant. If there are no children to Add or Update you can close that form.