Needs Assessment Form
Help us serve you, better.
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date
*
-
Month
-
Day
Year
Date
Annual Household Income***
*
Please Select
$0- $9999
$10,000-$49,999
$50,000 - $125,000
$125,000+
What's your age group?
*
Please Select
14-24 years old
25-50 years old
51-65 years old
65+ years old
Prefer not to disclose
Ethnicity/Culture
*
Please Select
African-American/Afro-Carribean/Afro-Latin/Black
Asian
Caucasian/European/White
Indigenous/Indian/Native American
Non-black Latinx
Multi-cultural
Other
Prefer not to disclose
Gender Identity
*
Please Select
Cisgender Female (born female)
Transgender Female
Cisgender Male (born male)
Transgender Male
Prefer not to dislose
Non-Binary
Sexual Identity
*
Please Select
Straight/Heterosexual
Gay/Homosexual
Bisexual
Pansexual
Fluid
Non-confirming
Prefer not to disclose
Do you want to get more involved in the community?
Please Select
Yes
No
Unsure
Already involved
What services and/or activities would your family/household most likely engage and/or be interested or involved in if offered by a program / residential community / school / local community center?
*
Youth Mentorship (culture field trips, soft skills training, big bro/big sis peer matching)
Financial Literacy workshops
Arts Programs (poetry, music, drama/theater, visual arts, media arts (film/video/editing)
Community Goodwill (service volunteering, community trash pickup, fundraising, etc.)
Free Summer Food program(s)
Job Coaching + Assistance
General human services (help with job appllication, help with food stamps application, etc.)
Other programs/services not listed above, please type in
What coping strategies and/or wellness activities would your family/household most likely engage and/or be interested or involved in if offered by a program / residential community / school / local community center?
*
Community sports engagement (e.g. kickball, soccer, etc)
Yoga/Meditation sessions
Community Roundtable talk sessions
Behavioral support services
Other coping strategies/wellness activities not listed above, please type in.
What educational support services would your family/household most likely engage and/or be interested or involved in if offered by a program / residential community / school / local community center?
*
Afterschool tutoring
Trade/Vocational prep
College prep
College tours/visits
How many members of your household would engage services?
*
0-4 youths aged 14-24
5-10 youths aged 14-24
10+ youths aged 14-24
0-4 adults aged 25-50+
5-10 adults aged 25-50+
10+ adults aged 25-50+
1 or more seniors 62+ in the household
What access barrier(s) might your household need support with?
*
Language Access
Transportation Access
Food Insecurity
Childcare Supports
None
Other
If you checked "other" please type in the access barrier(s) your household might face and need support with?
What accommodations might you need to access services/activities?
Language Access
Braille (Blind or hard of seeing)
American Sign Language (ASL, for Deaf or hard of hearing)
ADA wheelchair accessibility
Neurocognitively intact or is support needed
None
What is your general availability for participating in or engaging community services and activations?
*
Daytime Weekdays (Monday - Friday 9a-5p)
Daytime Weekends (Friday - Sunday 9a-5p)
Evening/Nighttime Weekdays (Monday - Friday 6p-10p)
Evening/Nighttime Weekends (Friday - Sunday 6p-10p)
Flexible/Open Availability
Mixed availability
Please descibe your Flexible/Open/Mixed Availability schedule
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