Community Support Survey

Name

Are you at risk of losing safe and/or stable housing in the next few months? Are you at risk of losing safe and/or stable housing in the next few months? YES NO

Is the place you are staying currently unsafe or unstable? Is the place you are staying currently unsafe or unstable? YES NO

Have you received shut-off notices from any utility companies in the past few months? Have you received shut-off notices from any utility companies in the past few months? YES NO

Have you worried about having enough food to feed your family in the past few months? Have you worried about having enough food to feed your family in the past few months? YES NO

Have you missed medical appointment because of lack of transportation in the past few months? Have you missed medical appointment because of lack of transportation in the past few months? YES NO

Have you not bought medications or skipped medical appointments because of lack of income in the past few months? Have you not bought medications or skipped medical appointments because of lack of income in the past few months? YES NO

Are you need of child or adult care? Are you need of child or adult care? YES NO

Are you in need of legal help? Are you in need of legal help? YES NO

Are you experiencing difficulty in relationships? (partner, spouse, family member, etc.) Are you experiencing difficulty in relationships? (partner, spouse, family member, etc.) YES NO

Have you felt unsafe, afraid, threatened, or hurt by someone currently in your life? Have you felt unsafe, afraid, threatened, or hurt by someone currently in your life? Yes No

Phone number (if you do not have a phone number or cannot accept calls, please respond with all 5’s)

Best Time to Call

Email Address