COVID-19 EMERGENCY RESPONSE
COMMUNITY NEEDS ASSESSMENT
Please take a moment to inform us of what services, programs, and other resources you need during these turbulent times. Your responses help to determine targeted assistance to help you and your families.
Perfer not to say
Same Gender Loving (Female)
Same Gender Loving (Male)
Has the individual contacted with people that were infected, suspected or diagnosed with COVID-19?
Have you or a family member been diagnosed with COVID-19?
Yes (not hospitalized)
No, but I think I have/had COVID-19 symptoms
No, I haven't had any medical issues due to COVID-19
Have you or a family member lost a job due to COVID-19?
Yes, I lost my job.
Yes, a family member lost their job
Describe your most pressing needs due to COVID-19.
Homless (No access to a shelter)
Homeless (Access to a shelter)
In your own or shared home/apartment
Staying with friends/family
In which of the following areas would you like assistance? (Select all that apply)
Health Services (COVID-19 Related)
Health Services (NON COVID-19 Related)
Mental Health (Referral)
Internet / Technology
Please advise in more detail if you need additional assistance based on your selections above.
Email - Please supply an email address so we can provide you with additional information or support.
Please add any additional comments here
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