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* 1. How do you identify?

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* 2. First and Last Name

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* 3. Email

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* 4. Phone Number

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* 5. During this time, are you safely able to meet your daily needs in the following areas:

  Yes, by myself Yes, with help from other people (family, friends, caregiver) Yes, with help from organizations No Does not apply to me
Having enough food
Having enough medicine
Getting help from caregivers
Service animal care
PPE supplies (hand-sanitizer, sanitizing wipes)
Medical supplies (urological, incontinence)

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* 6. Would you like to have access to online videos or resources about any of the following topics:

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* 7. What would be most helpful to assist you during this time?

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* 8. Have you contacted any organizations for information or help during this time?

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* 9. What are you most worried about during the COVID-19 crisis? (check all that apply)

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* 10. Anything else you would like to share?

0 of 10 answered
 

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