NEXT DOC COVID-19 NEEDS ASSESSMENT

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

Date of Birth *

MM

DD

YYYY

In response to the COVID-19 (Coronavirus) pandemic, what are your immediate needs? *

Please don't hesitate to select more than one.

Resources to obtain therapy

Finding a therapist

Paying for therapy

Freelance job opportunities

Other income

Rent, Utilities, internet

Solidarity organizing

Sharing of resources/information

Nodal Check-ins (Chicago, New York, Toronto, etc.)

Has anyone in your immediate family/community tested positive with COVID-19 (Coronavirus)? *

Yes

No

Do not wish to provide this information

Would a weekly check-in be beneficial to you? *

Yes

No

What kind of online (or otherwise) social activity would you be interested in participating in?

Check-in via phone calls/video calls

Collective Film Screenings

Bookclubs

Digital Lunch/Dinner dates

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

Country

(###)

###

####

Emergency Contact Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are they located in the same city as you? *

Yes

No