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The Empowered Survivor Project: Domestic Violence Assistance Fund
Domestic Violence incidents have been exacerbated by COVID-19. This form is to better understand the circumstances and needs of survivors seeking assistance.
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* Indicates required question
Name (First and Last)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age?
*
Your answer
Telephone Number
*
Your answer
Is it safe to call?
Yes
No
Clear selection
Is it safe to leave a message?
Yes
No
Clear selection
Please provide your full home address, including apartment unit number if applicable and zip code. If homeless, please provide information where you are currently staying (i.e. shelter, car, friend's home, etc.)
*
Your answer
Is this a safe address?
Yes
No
Clear selection
Email Address
*
Your answer
Race/Ethnicity
*
African-American or Black
Non Hispanic White
Hispanic or Latino
Asian
Native American
Other:
Gender Identity: Do you identify as LGBTQI?
*
Yes
No
Limited English Proficiency?
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Yes
No
Primary Language spoken?
*
Your answer
What's your country of origin?
*
Your answer
Do you identify with any of the following?
*
Deaf/Hard of Hearing
Veteran
Mental/Physical/ Cognitive Disability
Immigrant/Refugee/Asylum Seeker
Homeless
N/A
Other:
Required
What is your household size?
*
Your answer
What is your household income?
*
Your answer
Do you have health insurance?
*
Yes
No
Do you have special medical needs?
*
Yes
No
Please include the type of assistance needed:
*
Basic Needs
Financial Assistance
Rental Assistance
Required
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