Client Resource Needs

Client Resource Needs - Update

Para ver el formulario en español, haga clic en la bandera en la esquina superior derecha de la pantalla.

Pou w wè fòm nan an panyòl, klike sou drapo ki nan kwen anwo dwat ekran an.

Please complete this short questionaire about your need for resources for food, financial assistance, healthcare, parenting and childcare.

Resource information will then be emailed to you. You may receive several different emails.

Client #
The client # is on the sticker on your hand
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please double check that your email address is correct.

We cannot send you any information if it is wrong.
Is this your first visit to Mothers Helping Mothers?
Language
County

NOTE:

This information will only be gathered if the client qualifies for food assistance and lives in SARASOTA county. It is needed by ALL FAITHS FOOD BANK.

It will also be gathered if client answers NO to health insurance & visit doctor questions. It will be used by MCR Health
Client Name

First NameLast Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
A representative from All Faiths Food Bank may contact you to follow up and to offer you additional resources for food.
A representative from MCR Health may contact you to follow up and offer you resources for health insurance and medical care.

DOMESTIC VIOLENCE
Do you feel safe in your relationships at home?
We often work with parents who have experienced violence or are afraid of the other parent. We have information about resources that are available in our area if anything like this ever does come up, Mothers Helping Mothers is a safe place to talk about it and get help
This is not your fault. We are here to help. We often work with parents who have experienced violence or are afraid of another person in their home. We have information about resources that are available for you in our area. We are offering services to anyone who may be concerned about violence in their home.
Would you like resources to help with your domestic situation emailed to you?

You provided us with this email earlier:

{email}
Is this a safe email to send these resources?
Would you like to provide different email address to use to receive this information?
Second Email (DV)
example@example.com
We will not send you an email with these resources. You can take a picture of this screen if you would like.

1. IN AN EMERGENCY always call 911!
2. Domestic Violence Hotline 1-800-500-1119
3. SPARCC 24 HOUR HOTLINE: (941) 365-1976
4. Hope Family - 24 HOUR Hotline (941) 755-6805
For Your Safety...
It’s common for abusive partners to monitor your internet use. After you read the email you receive clear the site from your browser history. Consider using a device they don’t have access to. If you suspect you’re being monitored, consider using a computer at a library or using a computer at Mothers Helping Mothers. Your safety is a priority, and we’re here to help you take the necessary precautions. Online history could be accessible even if you delete your browser history and files. Learn more tech safety strategies at ceta.tech.cornell.edu/resources or call the National Domestic Violence Hotline at 1-800-799-7233