Clothing Insecurity Screening Form
Please complete this Clothing Insecurity Screening Form to help us understand your current clothing needs and arrange appropriate support.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone
Text Message
Number of People in Household
*
Age Groups Needing Clothing (select all that apply)
*
Infant (0-2 years)
Child (3-12 years)
Teen (13-17 years)
Adult (18-64 years)
Senior (65+ years)
Which types of clothing are currently needed? (select all that apply)
*
Everyday wear
Outerwear (jackets, coats)
Shoes
Work or school uniforms
Seasonal items (hats, gloves, rain gear)
Other
What barriers are you facing in accessing adequate clothing? (select all that apply)
*
Cost/affordability
Transportation
Limited local availability
Sizing/fit issues
Other
How urgent are your current clothing needs?
*
Immediate (within 1 week)
Soon (within 1 month)
Not urgent (can wait longer)
Preferred method for receiving support
*
In-person pickup
Delivery to home
Gift cards/vouchers
Is there anything else you would like us to know about your clothing needs or situation?
Submit
Should be Empty: