Needs Assessment for Single Mothers Impacted by the Altadena Fires
Thank you for taking the time to complete this needs assessment. The recent fires in Altadena have significantly impacted our community, and we want to ensure that single mothers and their families receive the support and resources they need to recover and rebuild. This form is designed to help us better understand your unique challenges, immediate needs, and long-term concerns following the disaster. Your responses will guide us in providing tailored assistance, from essential supplies and services to emotional support and community programs. Please rest assured that all information shared will remain confidential and be used solely for the purpose of creating meaningful support systems for those affected. If you have any questions or need help completing this form, feel free to contact us at info@afatherlessdaughter.org. We are here for you and committed to helping you rebuild with strength and hope. Thank you for allowing us to serve you.
Basic Information
First name
Last name
Email
Phone Number
Address
Are you a single mother?
Yes
No
How many children do you have?
How long have you lived in Altadena?
Impact of the Fire
Were you displaced from the fire?
Yes
No
What is your current housing situation?
Did you experience personal items or property loss in the fire?
Personal Items
Property Loss
Both
What challenges have you faced since the fire?
How have your children been impacted? (Select all that apply)
Loss of personal belongings (e.g., toys, clothes, school supplies)
Displacement from home (e.g., living in temporary housing or shelters)
Emotional distress (e.g., anxiety, fear, sadness)
Disruption of schooling (e.g., missed school days, difficulty focusing)
Physical health issues (e.g., smoke inhalation, injuries)
Separation from friends or family members
Increased financial strain on the family
No noticeable impact on my children
Other
If "Other" please specify
Employment and Financial Needs
What challenges are you currently facing related to employment or finances? (Select all that apply)
Loss of job due to the fires
Reduced working hours or income
Lack of access to childcare, preventing work opportunities
Increased expenses (e.g., temporary housing, food, transportation)
Difficulty accessing unemployment or other financial assistance
Limited job opportunities in the local area
What is your primary source of income?
Full-time employment
Part-time or temporary employment
Self-employment or freelance work
Government assistance (e.g., unemployment benefits, SNAP, WIC)
Child support or alimony
Savings or retirement funds
Family or community support
Other
Do you have access to childcare?
Yes
No
Do you need additional childcare support?
Yes
No
Emotional Wellbeing
How would you describe your current emotional well-being?
Managing well, despite the circumstances
Feeling stressed but coping
Struggling with overwhelming emotions
Experiencing anxiety or depression
Feeling hopeless or unsure where to turn for help
Are you interested in mental health support?
Yes
No
What kind of support would be most helpful to you? (Select all that apply)
Individual counseling or therapy sessions
Group therapy or peer support groups
Access to a mental health hotline or crisis support
Workshops or classes on stress management and emotional resilience
Resources for self-help (e.g., books, videos, apps)
Family counseling or parenting support
Other
If "Other" please specify
Immediate and Long-Term Needs
What are your most urgent needs right now? (Select all that apply)
Temporary housing or shelter
Food assistance
Clothing and personal items
Financial support or emergency funds
Childcare or school supplies for children
Access to medical care or prescriptions
Emotional and mental health support
Transportation assistance
Access to information about available resources
What long-term support would help you recover from the fire?
Community Feedback
Are there existing community resources you believe could be improved or expanded?
Would you be willing to participate in future discussions or focus groups about recovery efforts?
Yes
No
If "Yes", how would you like to be contacted?
Email
Call
Text
Additional Comments
Is there anything else you'd like to share about your experiences or needs?
Submit
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