Tri-TownCares is a joint effort by Madison Borough, Chatham Borough and Chatham Township in response to the COVID-19 pandemic, to connect residents with mental health and emotional wellness resources.
Survey Purpose: To improve the services provided by not only Tri-Town Cares but by other volunteer organizations seeking to address the emotional and mental well-being of residents. Please note that all responses are confidential.

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* 1. Please indicate what best describes your situation:

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* 2. Please slect the option that best describes your family support system:

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* 3. Please select the one that best describes your extended support system:

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* 4. Please mark off the age group(s) of residents in your home: (Please mark all that apply)

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* 5. What town do you live in:

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* 6. Please check which living situation best describes your residence:

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* 7. Please describe what best fits your neighborhood/apartment complex prior to the pandemic

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* 8. Please describe what best fits your neighborhood/apartment complex now:

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* 9. How has your living situation changed since the beginning of the stay at home order:

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* 10. Are there services that would be important to have, which of the following might it be? (check off all that apply):

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* 11. If you are now living with others, what statement best decribes the way you feel:

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* 12. Please advise how isolated/lonely you feel:

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* 13. In our household, the following individuals have had a significant increase in their stress levels during the pandemic and stay-at-home order. (Check all that apply)

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* 14. The source of the pandemic-related stress in our household is due to the following (Check all that apply):

Please rate the following statements

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* 15. I/we have strong concerns about getting infected by the virus

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* 16. I/we have been having an increased sense of isolation

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* 17. I/we have concerns about job stability or change in financial status

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* 18. I now feel safer going out in public with social distancing measures in place

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* 19. I now feel we should be able to go back to "normal" by lifting restrictions

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* 20. I/we are increasingly afraid of food insecurity.

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* 21. I/we are increasingly afraid of health related issues.

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* 22. The pandemic has hurt my relationship with family members or friends

Please rate the following questions based feelings and health over the last month

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* 23. My mental health has prevented me from participating in my regular activities

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* 24. I have felt down, depressed or hopeless

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* 25. I've had trouble falling asleep, staying asleep or sleeping too much

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* 26. I've had little interest in doing activities I used to enjoy

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* 27. I've felt worried, tense or anxious

While all responses are confidential please answer the next question only if you are comforable.

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* 28. Has your alcohol or substance usage changed since the start of the pandemic?

Thank you very much for your time and responses. The input from the survey will help the Tri-Town Cares partnership respond to the needs of our community and plan for future challenges.
If you need mental health support, please go to www.TriTownCares.org for resources and programs.

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