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Emergency Support Assessment
This survey is designed to assess your needs and connect you with resources:

As families, some with children, we are all impacted by COVID-19 Quarantine. Reduced financial income, lack of basic needs and/or illness due to the virus is REAL.

We encourage everyone to practice self quarantine and EXTREME social distancing, wash hands & face, call support people, practice daily Gratitude journals and help your community as much as possible.

You can come back anytime to submit a new form as your circumstances change.

AS A COMMUNITY WE WILL OVERCOME ALL ADVERSITIES.
Email *
Name and Phone Number *
Todays Date *
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Q1. I am a survivor of human trafficking, gender violence or commercial sexual exploitation.
Clear selection
Q2. I need help with (check all that apply)
Moderate Alert
Major Concern
High Alert
Emergency Status
Toiletries
Food
Transportation
Emotional Distress
Mental Distress
Emergency Housing
Other
Q2 I'd like to learn or attend virtual classes (check all that apply)
Don't Need
Need
Really Need
Need NOW!
Meditation
Yoga
Healthy Eating Recipes/Support
Exercise
Filing Taxes
Calming Anxiety Mini Class
Q3. My family size includes: list ages of all in the home
Q4. I live in (City, State)
Q5. Add any additional comments or concerns to help us develop the most effective assessment
CONTACT US OR FIND OUT MORE...
(877) 436-7338

www.victorygardensanctuary.org
www.shynesd.org

To help us BEST address the growing needs of our community please allow Up to 72-hrs for response

STAY INSIDE & STAY HEALTHY!
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