Gender:

Male

Female

Non-Binary

Choose Not To State

Ethnicity:

Asian / Asian American

Black / African American

Hispanic / Latinx

Indigenous / Native American

Native Hawaiian / Pacific Islander

White / Caucasian

Choose Not to State

Disability / Diagnosis:

Breast Cancer

Cognitive

Developmental Disability

General Cancer

Hearing

Learning Disabled

Mental / Emotional

Multiple Disability

Physical

Substance Abuse

Systems Disease

TBI

Vision

Other

Name Other Disability or Diagnosis

Benefits / Services Received:

Calfresh

MediCal

SSI

VA Benefit Recipients

Section 8 / HUD

Public Housing Recipient

Caregiver / Service Provider:

I am a Caregiver.

I am a Service Provider.

I neither a Caregiver nor Service Provider.

Annual Income Information:

Employment / Job

General Assistance (GA)

Pension / Retirement

Self-Employed / Business

SSDI

SSI

Other

Name Other Income

Marin County Residency:

Yes, I currently live in Marin County.

No, I do not live in Marin County.

Home Type:

Single-Family Home

Townhouse / Condo

Apartment

Mobile Home

Facility

Transitional

Choose Not To State

Occupancy:

Own

Rent

Choose Not To State

Digital Access:

Do you have access to a device (made within the last 2 years) that can go online?

Yes

No

Do you currently have access to high-speed internet?

Yes

No