Women Only Social Assistance Survey
Ladies, please complete this survey as best as you can to help us understand your needs, provide support, and direct you to appropriate local resources.
Full Name/Nickname
*
First Name/Nickname
Last Initial
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age Range:
*
Under 16
16-18
19-21
22-29
30-35
36-40
41-46
47-54
55+
How many dependents do you have?
*
What type of assistance do you need? (Select all that apply)
*
Childcare Support
Continued Education
DV / SA Trauma Support
Employment Assistance
Food Assistance
Housing Support
Immigration Assistance
Maternal/Pregnancy Support
Medical Assistance
Sobriety Support
Transportation Assistance
Youth/Teen Empowerment
Other
Current Employment Status (select all that apply):
*
Student
Full-Time Employment
Part-Time Employment
Self-Employed
Homemaker/Caregiver
Unemployed
Other
Marital Status
Single
Married
Widowed
Divorced
Other
Types of workshops/activities interested in the future (select top 5):
Physical self-defense training (striking, weapons, range days, etc)
Creative therapy (art, writing, music, crafting, etc.)
Healing thru movement (yoga, hiking, dance, etc.)
Situational awareness workshops (reading red flags, setting boundaries, conflict resolution, etc)
Ladies only spaces (potlucks, networking, women circles, etc)
Digital self-defense (online stalking, algorithms, digital footprints, surveillance, etc)
Children & predator awareness (grooming, bullying, etc)
Skill Building Workshops (gardening, carpentry, mechanical, electrical, etc)
Have you attended a FREE Self Defense Program class?
Yes
No
Please share any additional information about your situation or needs.
Submit Survey
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