Official BLM Wellness Checks
We know there have been lots of people impacted by the storm. We are trying to understand What people need the most. Please fill out the survey and share it with someone you know
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Is the phone number you listed above a cell phone?
Yes
No
Email
example@example.com
What is your current zip code
Do you live in the City of Memphis
Yes
No
Unsure
How many people are in your household?
Do you have running water?
Yes
No
If you have running water, Do you feel safe using it this time?
Yes
No
Unsure
Do you have access to food?
Yes, food is not an immediate need
No
Yes, I have food now but only a small amount
Did you have Secure and Safe Housing prior to the storm?
Yes
No
If No, please share your concerns
Do you now have unsafe or insecure housing or have these existing issue gotten worse because of the storm?
Yes
No
Unsure
If you now have unsafe or insecure housing as a result of the storm, please explain below
Are you Facing Eviction?
Yes
No
Unsure
If you are facing eviction , have you received an eviction notice and a court date?
Yes, I have received an eviction notice but not a court date
Yes, i have received an eviction notice and a court date
No
Unsure
Do you have transportation?
Yes, I have my own car
Yes, I ride the bus
Yes, I have access to someone with a car
No, I have no access to transportation
Do you have existing medical needs?
Yes
No
If you have existing medical needs, please explain below
Please list any other immediate or emergency needs not listed above
Do you have a loved one in a jail or prison in Memphis or Shelby county?
Please Select
Yes
No
Do you know the wellness status of your loved one that is being held in a Memphis or Shelby County jail or prison at this time?
Yes
No
Unsure
Please share any details or needs for your loved one being held in a Memphis or Shelby county jail or prison below
Can we call, text or email you to follow up on your needs?
Yes
No
Submit
Should be Empty: