Privilege Based Price Scale 
I encourage you to be vulnerable and honest with this survey. 
* Basic Needs are defined as Housing, Utilities, Food, Transportation, Childcare and Health Insurance.
Sign in to Google to save your progress. Learn more
Email *
What best describes your experience? *
Are you supporting Dependents? *
Do you qualify for Public Aid? *
Do you have Debt? *
What best describes your Financial Situation? *
What best describes your situation? *
What best describes your situation? *
What is your Employment Status? *
What best describes your Health Care access? *
What best describes your experience? *
What best describes your experience? *
Are there any other possible factors that you'd like Tidy Den to consider while determining your privilege based payment level? 
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy