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COVID-19 Breakthrough Survey
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Breakthrough Student Name/s
*
Your answer
How many children are in your household? (Under 18)
*
Your answer
How many adults (including yourself) are in your household?
*
Your answer
Do you have internet in your home?
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Yes
No
Other:
Does your family have a home computer?
*
Yes
No
Other:
Is your family currently experiencing financial strain due to the COVID-19/Coronavirus outbreak
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Yes
No, we're doing fine
Maybe, it's too early to tell
Explain Below
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Your answer
Will you be able to continue work during this time?
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Yes
No
Maybe, it's too early to know
Explain Below
*
Your answer
Should the COVID-19 outbreak continue, what are you most concerned about in the next 2-3 months?
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Your answer
Are you concerned about your student's mental health right now?
*
No, my student is doing well right now
Yes, I would like my student to receive a call from Breakthrough's Student Success Coordinator (licensed medical health professional)
Yes, I would like my students to receive a call from one of the Breakthrough full time staff to check-in.
Maybe, it's too early to know
Will your student's school offer online learning?
Yes
No
Other:
Clear selection
What resources does your student(s) need right now?
SAT/ACT Test Prep
Tutoring in core subjects
Ideas for home activities
Materials (Pens/Paper)
Group chats or videos with other Breakthrough students
Other:
Best Phone Number
*
Your answer
Best Email Address
*
Your answer
Is there any additional information you would like Breakthrough to know?
Your answer
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