Shelter Resident Intake Survey
Thank you for your help! Although doing this is voluntary, your answers to these questions will help our program understand and improve the services we provide. We do not ask for your name. your answers are confidential are very important us. Please respond honestly. When you have finished, put this form in the envelope you were given, seal it, and put it in the place the staff member showed you.
___ ___ ___ ___ (Write in the first 2 letters of your mother’s first name, and the first 2 numbers of your most recent address, e.g., WE17. No one will be able to connect this information with you, but it will allow us to better meet resident’s needs. If you still do not feel comfortable with this, please use two letters followed by two numbers that you will remember and can use again later. If you filled out the Intake survey (survey #1). Please use the same letters and numbers you used then.
- Where have you heard about this emergency shelter? (Please check all that apply)
___ Telephone book ___ Domestic violence (DV) advocate, incl. other DV shelter
___ People in court ___ Family member
___ Health care provider ___ People from my religious/spiritual community
___ Police ___ Child protective services staff
___ TANF (welfare) staff ___ Friend(s)
___ Flyer/brochure/poster ___ Social service agency staff, incl. homeless shelter
___ Other (where?) _____________________________________________________
- When was the first time you heard about this shelter?
___ A day or two ago ___ More than a day or two, but less than a month ago
___ Between a month and a year ago ___ More than a year ago
- Have you ever stayed at this shelter before? ___ No ___ Yes
(If yes): How long ago did you stay here?
___ In the past 6 months ___ 6 months to a year ago ___ More than a year ago
- When you decided to come here, what did you think this shelter would do for you?
___________________________________________________________________
- Did you have any concerns about contacting this shelter? ___ No ___ Yes
(Please describe your concerns): ________________________________________
- Have you ever tried to stay at this shelter in the past and no been able to do so?
___ No ___ Yes
If yes: what was the reason you couldn’t stay here? _________________________
- Please check all of the following that were true for you when you first arrived here this time:
___ The staff made me feel welcome ___ The staff treated me with respect
___ The space felt comfortable ___ It seemed like a place for women like me
___ The other women made me feel welcome ___ None of these choices were true for me
- What do you think you would have done if this shelter didn’t exist?
___________________________________________________________________
- While I’m here I hope I can get help with (check all that apply to you: there are no “right” answers):
___ safety for myself ___ transportation
___ safety for my children ___ support from other women
___ learning about my options and choices ___ a job or job training
___ paying attention to my own wants and needs ___ counseling for myself
___ paying attention to my children’s wants
and needs ___ counseling for my children
___ understanding about domestic violence ___ emotional support for myself
___ safety planning ___ health issues for myself
___ education/school for myself ___ health issues for my children
___ education/school for my children ___ my abuse-related injuries
___ reconnecting with my community ___ leaving my relationship
___ budgeting & handling my money ___ TANF (welfare) benefits
___ child protection system issues ___ other government benefits
___ child welfare system issues ___ legal system/legal issues
___ protective/restraining order ___ my abuser’s arrest
___ my own arrest ___ custody or visitation questions
___ divorce-related issues ___ immigration issues
___ ideas for handling the stress in my life ___ childcare
___ connections to other people who can help me ___ finding housing I can afford
___ responding to my children when they are upset
or causing trouble ___ other (what?): __________
We ask the next questions to see if different
women have different experiences here, so we can continue to improve our
services for ALL women. But please leave any blank if you are concerned it
- I consider myself to be:
___ African American/Black ___ Asian
___ African ___ Asian American
___ Native American/Alaska Native ___ Hispanic/Latinx
___ Middle Eastern ___ Native Hawaiian/Pacific Islander
___ Multiracial ___ White/Caucasian
___ Prefer not to answer ___ Another identity (please specify): _____
If there is a particular ethnic background that is important to you, please identify: _____
- My age is:
___ 18-24 ___ 25-34 ___ 34-44 ___ 44-54 ___ 55-64 ___ 65+ ___ Prefer not to answer
- I am:
___ Cisgender woman ___ Cisgender man
___ Transgender woman ___ Transgender man
___ Genderqueer/Non-Binary ___ Agender
___ Two-spirit ___ Another Identity (please specify): ___________
___ Prefer not to answer
- I have ________ minor children (age 17 or younger). Write in the # of children you have under age 18.
- Please write in # of children with you in shelter in each age group:
___ Under 1 year old ___ 1-5 years
___ 6-12 years ___ over age 12
- I consider myself to be
___ Straight ___ Bisexual ___ Gay/Lesbian/Queer ___ Prefer not to answer
___ Another (please specify): _________________
- The highest level of education I have so far is:
___8th grade or less
___ 9th-11th grade
___ High school graduate or GED
___ Some college
___ College graduate
___ Advanced degree
Thank you very much!!