Moms of Special Born Angels: Housing Support Survey
Moms of Special Born Angels supports parents and caregivers of children with special needs. If you are facing, or at risk of, homelessness, we want to hear from you. Your answers help us connect families to resources and advocate for housing support. This survey is confidential, and you may skip any question you prefer not to answer.
I understand my answers will be kept confidential and used only to connect families with resources and support.
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Yes, I understand and agree
No
Your name (first name or nickname is fine)
First Name
Last Name
Best phone number to reach you (optional)
-
Area Code
Phone Number
Email address (optional)
Preferred way to be contacted
Phone call
Text message
Email
Please do not contact me
What city/county and state do you currently live in or stay in?
*
Which best describes your current housing situation?
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Staying in a shelter
Staying with family or friends (doubled up)
Living in a car or public place
Staying in a motel/hotel
Facing eviction or foreclosure
Behind on rent/mortgage but still housed
Fleeing domestic violence
Other
How long have you been without stable housing (or at risk)?
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Less than 1 month
1-3 months
4-6 months
7-12 months
More than 1 year
What led to your housing instability? (Select all that apply)
Job loss or reduced hours
Cost of caregiving or medical bills
Eviction or rent increase
Domestic violence
Lack of affordable housing
Unsafe or inaccessible housing
Loss of benefits or services
Other
How many adults are in your household?
*
How many children are in your household?
*
What special needs does your child (or children) have? (Select all that apply)
Autism
Developmental or intellectual disability
Physical disability or mobility needs
Medical complexity
Mental or behavioral health condition
Learning disability
Sensory needs
Other
Prefer not to say
What housing accommodations does your child need? (Select all that apply)
Wheelchair accessible
Ground floor or elevator
Quiet/low-stimulation environment
Close to school or therapy
Medical equipment space or power needs
Safe fenced or secured space
None
Other
Which services is your family currently receiving? (Select all that apply)
Medicaid
SSI/SSDI
SNAP
CDPAP / self-direction
Respite services
School IEP/504 services
Early Intervention
Housing assistance/voucher
None of these
Other
What are your most urgent needs right now? (Select all that apply)
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Emergency shelter
Affordable or accessible housing
Rental or eviction assistance
Food
Transportation
Childcare or respite care
Medical or therapy access
Legal help
Employment or income support
Emotional support or parent peer support
Other
Do you have a safe place to stay tonight?
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Yes
Not sure
No
Have you had difficulty getting help from shelters or agencies because of your child's needs?
Yes
No
Not applicable
Is there anything else you would like us to know about your family's situation or what would help most?
Would you like someone to follow up with you about resources?
*
Yes
No
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