Unmet Needs Assessment Form
If you have needs that are not currently being met through other sources, our long term recovery group wants to help.

Trained disaster recovery case managers will assist individual victims to assess disaster-related needs, and connect you with appropriate providers.

Once the form is received, you will be contacted within 45 days.

PERMISSION: By submitting this form, I am granting the North Florida Inland Long Term Recovery Group (NFI LTRG) permission to share this information with their partner service providers, governmental agencies, volunteer/faith based organizations, and any other entity that is able to assist in meeting my household’s unmet needs. *
First Name *
Your answer
Last Name *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Telephone Number *
Your answer
Alternate Number
Your answer
Email Address
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Where do you live? *
Do you own or rent your home? *
How long have you lived at your current residence? *
Your answer
How many people live in your household? *
Your answer
Ages ranges of those in your household (check all that apply): *
Required
Is anyone in your household a veteran? *
Does any member of your household have a disability or special needs? *
Of the options below, please select your needs. *
Required
Where are you currently living? *
If your home needs repairs, check all that apply. *
Required
Do you have additional needs or concerns? If so, detail here:
Your answer
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This form was created inside of North Florida Inland Long Term Recovery Group.