Intake for families impacted by Summer 2023 heavy rains in eastern Pennsylvania
This form is being used to gather information from individuals and families impacted by heavy rains in eastern Pennsylvania after heavy rains in July, 2023. While there is no guarantee of services, this information helps partner organizations across Pennsylvania to understand unmet needs and to develop resources and support for disaster survivors. 
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Email *
Consent: Thank you for your time today. This short interview/survey should take about 10 minutes to complete. It will include questions about you, your home, and your current situation. Your information may be shared with a network of agencies, mostly government and non profit, to help you and/or your family access services and assistance you may be qualified for. Do you agree to your responses to these questions being shared with those agencies? *
First Name *
Last Name *
Date of Birth *
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Street Address (Pre disaster) *
City *
State *
Required
Zip Code *
What municipality do you live in?   (municipality may not be the same town name as your mailing address)  If you don't know, respond, "unknown". *
County [please choose which County the damaged property is located in] *
Best Phone Number *
What is your primary language?
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