The Puerto Rican Crisis Impact

Please share your personal experience. All testimonials are confidential without express written consent.

What is your first name?

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* 1. What is your first name?

What is your age?

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* 2. What is your age?

What is your gender?

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* 3. What is your gender?

In what language do you speak most often?

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* 4. In what language do you speak most often?

Hometown in Puerto Rico

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* 5. Hometown in Puerto Rico

What city do you currently live in?

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* 6. What city do you currently live in?

Email

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* 7. Email

Phone

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* 8. Phone

Referring Organization

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* 9. Referring Organization

Coordinating Staff Person

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* 10. Coordinating Staff Person

Do you agree to being publicly identified in the media/social media?

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* 11. Do you agree to being publicly identified in the media/social media?

How have you or your family been impacted by the debt crisis and economic decline in Puerto Rico (layoff, pension taxed, lack of doctors, energy costs, moved to the mainland, housing problem, other)? Please include key dates, specific financial impact, compelling human interest stories.)

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* 12. How have you or your family been impacted by the debt crisis and economic decline in Puerto Rico (layoff, pension taxed, lack of doctors, energy costs, moved to the mainland, housing problem, other)? Please include key dates, specific financial impact, compelling human interest stories.)

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