Assuming you're redoing the application, just a quick typo note: in the "Qualification" section, you have an unneeded apostrophe in the word "Steps".
Can you do a follow-up questionnaire to assess impact? I agree with Sara about the multiple choice, but I also think that having a comments section might be helpful if you have any experience in analyzing qualitative responses. Basically, you read through comments and identify common themes. Obviously subjectivity is a bit of a factor in that, versus less subjectivity in analyzing a quantitative survey, but sometimes getting quotes can be a powerful addition to a grant application or report.
I just wonder that with your current layout, is there any room for a few more questions. Of course, in a follow-up you face the problem of people not replying. If you put it on the application as required, then they have no choice.
The more I think about it...the more I like Sara's idea.
You could phrase it very simply. I'm sure you hear from the people you assist which are the most common reasons--cost is obviously the big factor, but it is not the only one. Work schedules, language barriers, transportation issues, are, I think the big ones. And definitely include an option for "Other" with a SMALL write-in space.
"Please indicate which (mark all that apply) barriers your household faces in getting its pets spayed or neutered"
#Medicine,SurgeryandSterilization