PLAN Family Check-in

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* 1. Can you please tell us your name and email?

First & Last Name

Email Address

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* 2. What is your biggest concern/fear during the COVID-19 crisis?

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* 3. Has someone connected with you in a meaningful way today? This week?

Yes

No

If Yes, can you tell us about it?

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* 4. Have you reached out and connected with someone you consider at risk of being isolated recently?

Yes

No

If Yes, can you tell us about it?

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* 5. Is there anything we can do to support you to feel more connected? (phone you regularly, set up a video chat, reach out to someone you know to suggest you stay connected)

Yes

No

If Yes, what can we do to support you to feel more connected?

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* 6. Have you done something to support others? (shopped for groceries or other necessities, picked up medication or run an errand for someone?)

Yes

No

If Yes, can you share your story?

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* 7. Is there anything we can do to support you? (shop for groceries or other necessities, pick up medication, run an errand)

Yes

No

If Yes, what can we do to support you?