Resource Questionnaire
Who is filling out this form
write your name here
Parent / Guardian Name
First Name
Last Name
TFC Youth
First Name
Last Name
Other Children in Household
Number of People in Household
How are you and your family currently doing?
How is your family currently doing on food supplies?
Great
Okay, but we may need help soon
We need help now
Are you missing any staples that we can provide right now?
If we were able to get fresh fruits and veggies, would you be interested in receiving some of them?
Yes
No
What programs are you currently in?
Cal Fresh/ Food Stamps
WIC
Nevada County Food Bank
Interfaith Food Ministry
Other
What is your transportation like currently?
I can get to and from the food stores/banks or The Friendship Club to resupply as needed
I have no means of transportation
Other
If it becomes available and we were able, would you and your family benefit from assistance with transportation?
Yes
No
If yes, for what in particular?
What technology do you have at home? (check all that apply)
Computer access
Internet access
Tablet with cellular data and/or internet
Smart phone with cellular data and/or internet
Other
What technology is your youth allowed to have access to at home? (check all that apply)
Computer access
Internet access
Tablet with cellular data and/or internet
Smart phone with cellular data and/or internet
Other
What streaming services does your family have? (check all that apply)
Facetime
Zoom
GoToMeeting
No video or streaming service
Other
If no, why not? (They may have internet, but it's not reliable, spotty, or may cost too much to use data streaming, find out more details)
What programs do you think are important for your child to continue participating in during this time even if done over the phone or internet? (check all that apply)
Therapy
Mentoring
Tutoring
Group meetings
Other
Would you like some resources for things to do during this social isolation?
Yes
No
Are you concerned about the potential for lost income during this time?
Yes
No
Do you need help or guidance with filing for unemployment if your hours are reduced or you are unable to work during this time?
Yes
No
Are you receiving our Remind messages?
Yes
No
If not, would you like us to add a number or email address to Remind for you?
-
Area Code
Phone Number
What is the best email to send resources to?
example@example.com
Are there any other immediate concerns you have for you, your family or child's wellbeing at this time?
Other notes from family
Student Specific Notes
Submit
Should be Empty: