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* 1. What is your name? (Can leave blank or answer anonymous)

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* 2. Would you like for a staff member to contact you at this time?

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* 3. What is your preferred method for contact?  Please select the method and add contact info as well. If you do not wish to be connected, enter N/A/ under contact information.

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* 4. Have you lost your main source of income due to COVID-19/Coronavirus crisis?

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* 5. Are you currently sheltered-in-place with your abusive partner (in the same home) or feeling unsafe in your living situation?

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* 6. If you are feeling unsafe, what are the barriers that are preventing you from leaving? Please list or describe. 

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* 7. If limited or no support is made available, will you need to rely on your abusive partner in any way?

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* 8. What are your most urgent needs right now? (Click all that apply and/or use the box to describe more.)

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* 9. What would be the most helpful thing that the Family Justice Center of Sonoma County could provide for you during this time?

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* 10. Would it be helpful for you have services available virtually, rather than just over the phone? If so, which services would you utilize the most?

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