What Ethnicity best describes you?
Choose
Hispanic, or Latino or of Spanish Origin
American Indian, or Alaska Native
Native Hawaiian or Other Pacific Islander
Black/African American
Black Non-African American
Asian
White
Two or More Races
With which gender do you identify?
Choose
Woman
Man
Non-Binary
Prefer not to answer
Other
What is your age?
Choose
16-20
21-29
30-49
50-64
65+
If you received services on-site, or through the Call Center, please select the closest statement that describes your interaction with staff. (Check all that apply)
Did you receive the services you were seeking?
If you answered no, please explain why, and add any additional programs or services that you believe would help your current situation.
Please choose the option that describes your contact with IMPACT for this survey. Choose
What Service(s) did you receive?
*
If you received other services, please describe them below:
If you have already received services, how would you rate your level of satisfaction?
If you were less than satisfied, please tell us how we can improve?
Would you recommend IMPACT to others?
If COVID-19 has negatively affected your life, please tell us how. (check all that apply)
If you answered other, please describe how else COVID-19 has affected your life
Please tell us how we can help your recovery from COVID-related barrier.
Any other comments or needs that were not mentioned in the previous question?
