I NEED HELP

ABOUT YOU

We care about you. Tell us about yourself, and what you need. Sharing your situation gives us some information to understand your situation, and how we might help. Please answer each question accurately and thoughtfully. Be confident your information is confidential; and you will remain anonymous. If you have questions or need assistance completing this form, please contact us at info@wingsforjustice.com.

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* 1. Contact Information

Name *

County *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number

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* 2. Are you male or female?

Male

Female

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* 3. What is your age?

17 or younger

18-20

21-29

30-39

40-49

50-59

60 or older

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* 4. How many children are you a parent or guardian for and live in your household (aged 17 or younger only)?

None

More than 4

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* 5. Which of the following best describes your current relationship status?

Married

Widowed

Divorced

Separated

In a domestic partnership or civil union

Single, but cohabiting with a significant other

Single, never married

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* 6. Who, if anyone, currently lives with you in your household? Please include permanent residents only. (Please select all that apply.)

Child

Grandchild

Parent

Grandparent

Roommate / Friend

Romantic partner (spouse, partner, boyfriend, girlfriend, etc.)

None of the above

Question Title

* 7. Which areas do you need help with at this time? (Please select all that apply.)

How do I learn about the family court process?

How do I build my case?

What do I do if a spouse or partner is abusive?

How do I leave an abusive spouse or partner?

How do I protect my children from abuse?

How do I negotiate parenting time?

What do I do if parenting time is violated?

Where do I find emotional support?

Where do I find physical support (ex. housing, food, transportation)?

How do I find suggestions for my family court case?

How do I leave my current household?

How do I get a personal protection order PPO?

Other (please specify)

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* 8. What is the highest level of school you have completed or the highest degree you have received?

Less than high school degree

High school degree or equivalent (e.g., GED)

Some college but no degree

Associate degree

Bachelor degree

Graduate degree

Some graduate work but no degree

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* 9. Which of the following categories best describes your employment status?

Employed, working full-time

Employed, working part-time

Not employed, looking for work

Not employed, NOT looking for work

Retired

Disabled, not able to work

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* 10. Has anyone in your household ever served in any branch of the United States military, or not?

Yes, someone has

No, no one has

Not sure

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* 11. How much total combined money did all members of your HOUSEHOLD earn last year?

$0 to $9,999

$10,000 to $24,999

$25,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 to $124,999

$125,000 to $149,999

$150,000 to $174,999

$175,000 to $199,999

$200,000 and up

Prefer not to answer

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* 12. Do you currently receive government food assistance, or not?

Yes, I do

No, I do not

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* 13. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race?

White

Black or African-American

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

From multiple races

Some other race (please specify)

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* 14. Do you identify with any of the following religions? (Please select all that apply.)

Protestantism

Catholicism

Christianity

Judaism

Islam

Buddhism

Hinduism

Native American

Inter/Non-denominational

No religion

Other (please specify)

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* 15. Do you have any other comments, questions, or concerns?

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* 16. Wings for Justice's Terms of Service and Privacy Policy.

I have read and agree to the terms of service and online privacy policy.