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Name:
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Postcode
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Australian residents only
How did you hear about this site?
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Internet Search
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What is your household income?
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Less than $10,000
$10,001 - $25,000
$25,001 - $40,000
$40,001 - $70,000
$70,001 - $100,000
Greater than $100,000
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What is your age?
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Less than 13
13-18
19-25
26-35
36-50
Over 50
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Option 1
Option 2
Option 3
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Option 1
Option 2
Option 3
What are the top 3 issues in our community?
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Domestic Violence
Sexual Abuse
Depression
Chronic Mental Illness
Housing
Youth At Risk
Suicide
Drugs & Alcohol
Social Isolation
Unemployment
Racism
Pregnancy / Parenting Issues
Other - Please Specify:
Please select 3 options.
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