1513CHURCH Hope Assessment
Please fill out this form and click submit.
Name
*
Email
*
This address will receive a confirmation email
Phone
*
How did you here about 1513CHURCH?
*
Please select one option.
Friend/Family
Social Media
Website
Community Event
Other
Loneliness Assessment
How many people could you call at 2 AM with a real emergency?
*
Please select one option.
Zero
1
2-3
4+
How many people know your current biggest struggle?
*
Please select one option.
Zero
1
2-3
4+
How often do you feel lonely?
*
Please select one option.
Daily
Weekly
Monthly
Rarely
Rate your sense of belonging in your community. (1-10 scale)
*
Please select one option.
1
2
3
4
5
6
7
8
9
10
Select Option
1
2
3
4
5
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7
8
9
10
Financial Stress Assessment
How many days could you survive financially if you lost your income tomorrow?
*
Please select one option.
0-7
8-30
31-90
90+
How much do you have in emergency savings?
*
Please select one option.
$0
$1-$500
$501-$1000
$1000+
How often do you lose sleep over money?
*
Please select one option.
Daily
Weekly
Monthly
Never
Rate your financial confidence (1-10 scale)
*
Please select one option.
1
2
3
4
5
6
7
8
9
10
Select Option
1
2
3
4
5
6
7
8
9
10
Mental Health Assessment
Depression Screen
Over the last 2 weeks, how often have you been bothered by little interest or pleasure in doing things?
*
Please select one option.
Nearly every day
More than half the days
Several days
Not at all
Over the last 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?
*
Please select one option.
Nearly every day
More than half the days
Several days
Not at all
Anxiety Screen
Over the last 2 weeks, how often have you been bother by feeling nervous, anxious, or on edge?
*
Please select one option.
Nearly every day
More than half the days
Several days
Not at all
Over the last 2 weeks, how often have you been bother by not being able to stop or control worrying?
*
Please select one option.
Nearly every day
More than half the days
Several days
Not at all
Rate your overall life satisfaction (1-10 scale)
*
Please select one option.
1
2
3
4
5
6
7
8
9
10
Select Option
1
2
3
4
5
6
7
8
9
10
Submit
Description
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