Contact for Ridgefield Social Services

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Ridgefield Social Services is looking for an easy way to collect and sort information in case we need to make contact with you about any changes in the upcoming days and weeks. Please note this is not protected HIPAA protected information. Please only include an answer if you are comfortable answering. You may choose which questions to answer, but the more information we have will help us complete any tasks here at Town Hall.

Email *

First Name

Last Name

Do you live in Ridgefield?

Yes

Concerned friend/family member of someone in Ridgefield

Other

Clear selection

How can we best contact you? (email will be best for us)

Cellphone

Home phone

Social Media

Other:

How do you plan to gather your local news/information?

Facebook

Twitter

online newspaper

News/print media

Other:

Email (please double check it is spelled correctly)

Home Phone

Cellphone

Emergency Contact (name, how to contact, relationship)

Are you a family who receives free and reduced lunch assistance through the schools?

Yes

Clear selection

Have you had contact with Ridgefield Social Services in the past?

Yes

Other:

Clear selection

What are the top 3-5 short term concerns? (now-3months)

What are your top 3-5 long term concerns (+3months out)

Do you have a food need that requires help cooking? (i.e. a need for Meals on Wheels?)

Yes

Maybe

Clear selection

Can we continue to contact you during this health crisis?

Yes

Clear selection

Please describe your current household employment situation:

Is there something specific you need us to know about your potential needs? (health, food access, family, etc) Please keep in mind that this form is not protected health information. Only include description of what you think we need to know about you)

Please tell us about your household, Please be specific. # adults, # children under 18, # seniors.

Do you think you will need/want to use the food pantry if there are major disruptions in daily life? (work, school cancellations, etc)

I use the pantry and will need to continue using it.

I don't usually use the pantry, but may need to if there are major disruptions.

I will not use the pantry

I don't know if I will use the pantry.

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms