Introduction

Impacted by the floods?
Please fill out this needs assessment survey. The results will go towards helping the Community Foundation of the Texas Hill Country and local nonprofits assess need, advocate for more resources, and direct individuals into nonprofit assistance as it becomes available. Your participation will allow us to advocate for more resources for our community and strengthen recovery efforts. This isn’t an application for assistance, but you can opt-in to receive text messages about available new resources and assistance as they become available.

Hidden Fields

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Yes

Prefilled Survey Id

Prefilled Contact Id

[HID]Survey Event Name

[HID]Last Name (for survey name, pt2-only mapping)

[HID]Homeowner (for conditional mortgage question in part 2)

YesNo

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Primary Household Member Information

First Name

Last Name

Phone Number

Email (optional)

We strongly encourage you to provide your email address or that of a trusted friend or family member.

Preferred Method of Contact

Alternative Phone Number

Address Search

Please type your street address and city, and then click on the matching result. Please do not include apartment numbers or unit numbers.

Were you able to find you address on the map?

YesNo, I couldn't find my address and I would like to enter my address manually

Street Address

Unit or Apartment #

City

State

Zip Code

County

What is the primary language spoken at home?

If you selected "Other," please specify your preferred language below:

Overall impact

Which of the following best describes you?

I was residing in the disaster impacted areas at the time of the floods.I was visiting the disaster impacted areas at the time of the floods.A family member was was visiting the disaster impacted area at the time of the floods.A family member was residing in the disaster impacted area at the time of the floods.

Did you lose a household member during the flood?

YesNo

We are so sorry.

Please know that the Texas Health and Human Services runs a 24 hour support line offering free professional crisis counseling to Texas flooding survivors, families, first responders, and others affected by calling 833-812-2480. The call line is available in English and Spanish and has interpretation for other languages. All calls are confidential and answered 24 hours a day, 7 days a week by personnel specially trained to work with disaster survivors.

Household Members

Please share some information for us about your household composition at the time of the floods.

Anyone self-identifying as having a disability?

YesNo

Household member(s) aged 65 years or older?

YesNo

Veteran or active duty service member(s)?

YesNo

Child(ren) under the age of 18?

YesNo

Consent & Release

1. May we share your information with other nonprofit organizations involved in disaster recovery efforts? Connective is a disaster recovery nonprofit that is working in collaboration with the Community Foundation of the Texas Hill Country and other nonprofit organizations to help residents in our community recovery.

By responding "Yes," you are agreeing to the following: I authorize Connective to share my information, including my name and address with other disaster relief and voluntary organizations in partnership with our organization in order to coordinate disaster relief assistance. I understand that my information will be shared with participating members of my county's Long-Term Recovery Committee in order to direct community resources. I understand that I may revoke this consent at any time by contacting Connective (info@connectivetx.org).

YesNo

2. Are you interested in receiving text notifications about local, free resources and services in our area?
Connective Texts is a free service that sends subscribers 2–3 texts with local resources per week.

Disclosures:

You will receive up to 10 text messages/month from Connective related to nonprofit and government resources.
You confirm that you are the subscriber to the relevant phone number or that you are the customary user of that number on a family or business plan and that you are authorized to Opt In.
Message & data rates may apply.
You can opt-out at any time by replying “STOP” to the text messages you receive.
You can adjust my subscription settings by replying "HELP" to the text messages you receive.
You will be texted a reminder of instructions for opting out of text messages at least once a month.
Your phone number will not be shared with any other organization without your explicit consent.

If you agree to receive text messages as described above, please click "Yes" below.

Yes, send me texts with local resourcesNo, I do not want to receive these notifications

Do you have time to answer a few more questions about your household and needs right now? It will only take 5-10 minutes.

Yes

No

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Survey Initiation

Are you filling out this survey on behalf of someone else?

YesNo

If you are filling out this survey out on behalf of someone else, please select the option that best describes you:

Please select the name of the organization you represent or are volunteering with:

Please write the name of the organization or group you represent or are volunteering with:

How did you hear about the Needs Assessment?

If you selected 'Other', please specify where you heard about this survey:

If you were referred to the Needs Assessment by a non-profit or faith-based organization, please type the name of that organization:

Single-family home	Manufactured Home	Apartment
Duplex/fourplex	Condo	Townhome
RV

Less than $20,000	$20,000 to $34,999
$35,000 to $49,999	$50,000 to $74,999
$75,000 to $99,999	Over $100,000
Prefer not to say

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