Survey Form

Hello, and welcome,
We want to express our gratitude for your participation in our recent survey aimed at understanding household needs and crisis areas.
We want to assure you that all information gathered through this survey is treated with the utmost confidentiality and privacy. Our commitment is to safeguard your data and use it exclusively for the purpose of connecting you to services that can address household gaps and crisis areas effectively.
Rest assured, your responses will not be shared or disclosed without your explicit consent. Only at the request of the client, who is seeking assistance, will information be shared in order to connect them with relevant services and support. Your trust in sharing this valuable information is crucial, and we take our responsibility to protect your privacy seriously.
If you have any concerns or questions regarding the privacy of your survey responses, please feel free to reach out to us.

Thank you once again for your participation and trust.

Best regards,
PBICVR Staff
[email protected] / 870-730-1131.

* Indicates required field

Understanding of Agreement *

I Understand & Agree

Name *

First

Last

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

What is your household income? *

Family Assessment Question:

Are you open to home visits conducted by this program? *

Please list the number of individuals living in the household? *

How many children under the age of 18 years old reside in the home? *

How many children under the age of 18 years old claim this as their primary residence? *

How many adults over the age of 18 years old reside in the home? *

How many adults over the age of 18 years old claim this as their primary residence? *

Current ages of each member of the household? *

Describe any current stressors or household worries? *

Describe any life changes that may have happened within the last 6-9 months? *

What is the highest level of education does anyone in the residence holds? *

Describe your financial / money management skills? *

Community Assessment Questions:

Select OneDo you currently have stable housing? *

Do you currently hold stable employment? *

Do you have a stable income? *

Are your current resources meeting the essential needs of your household? *

Do you have reliable transportation? *

Do you own / maintain that transportation? *

Do you have access to technology (Smart Phone, Computer, Internet Availability, Etc.)? (Please list all that apply.) *

Is your household experiencing food insecurity? *

Do you currently have legal issues? *

If Yes, please give a brief explanation. *

Have you been convicted of any crime? *

If yes, please give a brief explanation. *

Health / Wellness Assessment Questions:

Describe any/all medical conditions that each adult (18+) member of the household is experiencing? *

Do any children (under 18 years old) in your household need medical services? *

Is physical activity encouraged or made a priority in the household? *

If yes, please briefly describe activities. *

Do any children in the household participate in activities made available through the child’s school? (sports, clubs, other activities) *

If yes, please briefly describe the activities. *

I agree to receiving marketing and promotional materials *

Submit