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Shelter Resident Intake Survey Updated

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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.

  1. 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?) _____________________________________________________

  1. 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

  1. 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

  1. When you decided to come here, what did you think this shelter would do for you?



  1. Did you have any concerns about contacting this shelter? ___ No ___ Yes

(Please describe your concerns): ________________________________________

  1. 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? _________________________

  1. 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

  1. What do you think you would have done if this shelter didn’t exist?


  1. 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

  1. 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:­­­ _____

  1. My age is:

___ 18-24   ___ 25-34   ___ 34-44   ___ 44-54   ___ 55-64   ___ 65+  ___ Prefer not to answer

  1. I am:

___ Cisgender woman                ___ Cisgender man

___ Transgender woman                        ___ Transgender man

___ Genderqueer/Non-Binary   ___ Agender

___            Two-spirit                             ___ Another Identity (please specify): ___________

___ Prefer not to answer

  1. I have ________ minor children (age 17 or younger). Write in the # of children you have under age 18.
  2. 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

  1. I consider myself to be

___ Straight   ___ Bisexual   ___ Gay/Lesbian/Queer   ___ Prefer not to answer

___ Another (please specify): ­­­­­­­_________________

  1. 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!!

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