The following confidential survey is designed to learn about what services your family needs and can afford. The information gathered will help us provide better access, higher quality, and more affordable services to your household. The survey should take less than 10 minutes to complete. Please be honest and candid in your responses. Thank you very much. (note: questions with asterisks are required)
Additionally, if you include your name, e-mail address and phone number you will be entered in a drawing for an Apple iTouch (for details on the iTouch go to http://www.apple.com/ipodtouch/). Any personal information collected will be used to contact and verify the winner of the iTouch drawing only.
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Those respondents who include their name, e-mail address and phone (for verification purposes only) will be included in our drawing for an Apple iTouch!

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Those respondents who include their name, e-mail address and phone (for verification purposes only) will be included in our drawing for an Apple iTouch!
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If you do not have any children proceed to question number 16.
State assistance includes such items as food stamps or health insurance
For each of the following services, please select the level of need!
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Do you need any transportation services for you, a spouse/partner, a child, a grandparent, etc.
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Do you have any need for pet grooming, feeding, walking or kennel services?
Write in other desired services not listed above
How much do you spend per month on the services you currently use
What is your overall satisfaction with the quality of services you use
What is your overall satisfaction with the value of services you use
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What is your total income before taxes or other deductions (gross earnings)
What is your current job title and industry