Life Anew Behavioral Health - Emergency Services Needs Assessment

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Thank you for taking the time to complete this anonymous survey. The goal is to understand the emergency service needs of our community and connect individuals with the right resources. Your responses will remain confidential and will help us provide better assistance.

Name

Phone

Zip Code

Household Size (Number of Residents)

Number of Children (18 yrs of age and younger) Please list all ages

Number of Seniors (65 yrs old and up)

Household Income

Do you currently need assistance with any of the following? (Check all that apply)

Gas / Utility Bill Assistance

Water Bill Assistance

Electricity Bill Assistance

Food Assistance (Food Stamps, Food Pantry, Meal Programs)

Housing / Rental Assistance

Emergency Shelter

Childcare Assistance

Transportation (Bus Passes, Ride Services)

Medical Assistance (Medicaid, Free Clinics)

Mental Health Counseling or Crisis Support

Other:

Are you currently at risk of eviction or homelessness?

Yes, I have received an eviction notice.

Yes, but I have not received an eviction notice.

No, but I struggle to afford rent.

No, my housing situation is stable.

Clear selection

Do you currently have access to enough food for you and your family?

Yes, we have enough food.

No, we need food assistance.

Sometimes, but we struggle to afford enough food.

Clear selection

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