GenaShaes House Needs Assessment

GenaShaes House Needs Assessment

Your voice matters. Please complete this brief survey to help us better serve women, pregnant moms, and families in Virginia. All responses are confidential.
SECTION 1: About You
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What is your age?*

Under 1818–2425–3435–4445+
What is your current status?*

PregnantFirst-time momMom with young children (0–2 years)Mom with children over 2 years oldGuardian or caregiverOther (please specify)
If other was chosen..
How many children do you have?*

0123 or more
What City do you currently reside?*

NorfolkSuffolkChesapeakeVA BeachHamptonNewport NewsWilliamsburgOther
What is your current living situation?*

Stable housing (own/rent)Staying with family/friendsTransitional housingHomeless or in shelterOther (please specify)
If other was chosen...
SECTION 2: Needs & Challenges
What are your top challenges right now?*

Affordable housingAccess to foodChildcareTransportationEmployment opportunitiesMental health and emotional supportAccess to prenatal/postnatal careParenting skills and supportEducation or job trainingFinancial assistance
What services would you like to see in your area?*

Diaper and baby supply assistanceParenting and life skills classesMental health counselingSupport groups for momsJob readiness and resume helpGED or education supportHelp applying for WIC, Medicaid, etc.Safe/affordable housing for momsAccess to doulas or birthing supportTransportation assistanceOther (please specify)
If other was chosen...
Have you used local agency/nonprofit services before?*

YesNo
SECTION 3: Moving Forward
Would you be interested in any of these programs from GenaShaes House?*

Transitional housing for pregnant momsHolistic training (parenting, finances, job readiness)Support group for momsBaby item/donation drivesMentorship or peer supportOther (please specify)
If other was chosen...
How would you prefer to be contacted for future services/events?*

EmailPhone/TextSocial MediaI prefer to remain anonymous
Would you like to be notified when our transitional home opens and services begin?*

YesNo
Section 4: GenaShaes House Workshops
As we prepare to open GenaShaes House Transitional Home, we'd love to offer workshops to help support and empower you. What topics would you be interested in? (Select all that apply):*

Pregnancy & newborn careMental health & wellnessGoal setting & planningJob readinessBudgeting & money managementNutrition & healthy habitsFaith & spiritual growthHealthy relationshipsLife skills (cooking, time management, etc..)Legal rights & resourcesOther
If you chose other, please explain.
Preferred way to attend*

In personOnlineBothUnsure
Thank you for taking the time to complete this survey. We look forward to connecting with you.
Should be Empty:

GenaShaes House Needs Assessment

SECTION 1: About You

SECTION 2: Needs & Challenges

SECTION 3: Moving Forward

Section 4: GenaShaes House Workshops

Thank you for taking the time to complete this survey. We look forward to connecting with you.