• Youth Support Survey

    Thank you for participating in this needs assessment survey. Your responses will help us understand the needs of youth and families in our community and guide the development of programs and services offered in our communities. Please put "N/A" anywhere the questions doesn't apply to you or any question you'd like to skip.

  • Your responses are confidential and help us develop our programming and connect youth with the best resources.

  • * Indicates required question

  • Title VI & Consent

    YOU HAVE RIGHTS!

  • Title VI of the Civil Rights Act of 1964
    Our Youth Memphis does not discriminate on the basis of race, color, or national origin in programs or activities receiving federal financial assistance. You have the right to participate in our programs and services without discrimination. If you believe you have been subjected to discrimination, you may file a complaint with Our Youth Memphis or directly with the appropriate federal agency.

    This means you are protected from discrimination in programs funded by the federal government.  

    For more information or to file a complaint, you can contact:

    Our Youth Memphis Title VI Coordinator: Pearlina Ivory, ouryouthmem@gmail.com

    U.S. Department of Justice, Civil Rights Division: www.justice.gov/crt

  • Do you understand your Title VI rights? *
  • Do you consent to complete this Needs Assessment survey? *

  • Demographics

    The first name, school, and photo of the scholarship winner will be posted on Our Youth Memphis website and social media!
  • Participant Date of Birth *
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  • Current education level: *
  • Participant Gender Identity *
  • Participant Race/Ethnicity *
  • Where are you completing this form?  *
  • What are your desired post-secondary plans? *
  • Is this your first time submitting this form or a follow-up? *

  • Youth Needs Assessment

    A snapshot of what you need most right now—school, life, and everything in between.  
  • How much support do you currently need?  *

  • ACEs Screener

  • A glance at early life challenges, because your story matters.

    Answer questions for time period before the age of 18.

  • Swore at, insulted, or put down before age 18?  *
  • Physically hurt (pushed, slapped, etc.)?  *
  • Adult sexual touching or abuse?  *
  • Felt unloved or unimportant at home?  *
  • Not enough food/clean clothes or felt unsafe?  *
  • Parents separated or divorced?  *
  • Household member mentally ill?  *
  • Household member incarcerated?  *
  • Substance use/abuse in the home?  *
  • Household member attempted/threatened suicide?  *
  • Often felt alone or unsupported?  *

  • Trauma Screener

    Spotting the bumps and bruises life left behind to guide better support.  
  • Experienced or witnessed serious accident/injury?  *
  • Lived through natural disaster?  *
  • Experienced violence at home or neighborhood?  *
  • Been bullied or harassed online/in person?  *
  • Lost someone close (family/friend)?  *
  • Have nightmares or flashbacks about something stressful?  *
  • Avoid people/places/topics because of past events?  *

  • Counseling & Mental Health

    Checking in on your mind’s well-being—because mental health is health.  
  • Which mental health services are most needed? *

  • Health Education & Prevention

    What you know (and want to know) about staying safe and informed.  
  • Sex Education - Would you benefit from comprehensive health and sex education?*

  • Additional Comments & Suggestions

    Your space to spill ideas, concerns, or “don’t forget this!” moments.  

  • Community Forum & Event Interest

    Tell us what gatherings, workshops, or events you’d actually show up for.
  • If Our Youth Memphis hosted events or forums, which topics would you be interested in?

  • Post-Survey (Follow-Up)

    You should complete this section if you have already completed the full Youth Needs Assessment within the past year and some time has passed. This keeps the form short for repeat participants while still tracking progress and impact.  

  • Since you last filled out this form…

  • Which of the following goals or tasks have you completed?  *
  • Did Our Youth Memphis help you with any of these goals?  *
  • Since your last survey, have your needs changed?  *
  • Would you like us to check in with you again in a few months?  *

  • Follow-Up Requests

    Let us know if you’d like us to reach back out and keep the conversation going.  
  • Would you like someone from Our Youth Memphis to follow up?  *
  • If Yes, what is your  preferred way to be contacted?

  • We kindly ask that you acknowledge your Title VI rights and provide consent in order to proceed with the survey.

  • Privacy Notice

    Your responses are confidential and shared only with trusted staff at Our Youth Memphis. If you are in crisis or in danger, call 911 or reach out to a trusted adult right away.  
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