Last Name
First Name
Email
Phone
(###)
###
####
Do any of the following describe your current housing situation?
(leave blank if you have stable housing)
Does your housing have any problems with any of the following?
(check any and all that apply)
In the last 12 months, has the water, gas or electric company threatened to turn off service to your home?
Yes or already shut-off
No
NA
How many bedrooms are in your home?
0
1
2
3
4
5
>5
NA
In the past 12 months, did you or others you live with ever eat smaller meals or skip meals because you didn’t have money for food?
No
Yes
Within the past 12 months, have you worried that your family's food would run out before you got money to buy more?
Never
Sometimes
Often
Within the past 12 months, did the food you bought ever run out while you didn’t have money to get more?
Never
Sometimes
Often
Please indicate which of the following (if any) describe a problem with your child's education:
Leave blank if none apply or you do not have children.
Do you need daycare, or better daycare, for your children?
Yes
No
NA
Do you have difficulties purchasing or obtaining items necessary for your child's care (i.e. diapers, clothing, school supplies)?
Yes
No
NA
Does your child have a reliable and safe way to get to and from school?
Yes
No
NA
Do you need help with securing or maintaining guardianship or custody of your child?
Yes
No
NA
In the past 12 months, have you been unable to attend any of the following due to lack of adequate transportation:
Leave blank if none apply.
Please check any and all that apply regarding your financials:
Leave blank if none apply.
Do you have a bank account?
Yes
No
Please check any and all that apply regarding your personal and/or family stability:
Leave blank if none apply.
Do you have concerns about your family’s immigration status?
Yes
No
NA
Are you interested in receiving resources about immigration concerns?
Yes
No
NA
If you have other concerns not mentioned above, please write a short description:
