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I Need Help
|
Critical Needs
About
About Us
Our Services
The Boutique
Get Involved
Prayer
Volunteer
Join our team
Blog
Contact
Donate
I Need Help
|
Critical Needs
About
About Us
Our Services
The Boutique
Get Involved
Prayer
Volunteer
Join our team
Blog
Contact
Donate
Guest Survey
Please enable JavaScript in your browser to complete this form.
What is your name?
*
If not willing to give a name, use "Guest".
What is your age? (If willing)
(Record age if given)
What is the gender of the guest?
*
Female
Male
Other
(Record gender)
Why are you using the services at the Upper Room Mission?
*
I live on the street
I live in poverty
I cannot provide for myself
I don't know how to cook
I like the community
No other place to go to
Other
Why are you using the services at the Upper Room Mission?
Homelessness
Are you homeless?
*
Yes
No
A homeless person is an individual without permanent housing who may live on the streets; stay in a shelter, mission, single room occupancy facilities, abandoned building or vehicle; or in any other unstable or non-permanent situation.
What caused you to become homeless?
*
Lack of affordable housing
I choose to be homeless
Discrimination
Lack of adequate income
Traumatic events
Alcohol and drug addiction
I was involved in a crime
I lack access to physical and mental health supports
Domestic violence
Other
Other causes
*
Where do you sleep?
*
An apartment or home that you owned or paid rent on
A hotel or motel room that you paid for
A room or couch with family or friends
A hotel or motel room with Turning Points
At the shelter
A room at My Place, Our Place, The Crossing
A room at a Pivot Property
A room at Blair Apartments
In Polson Park or any other park in Vernon
In an encampment
In a car, camper or other vehicle
Anywhere on the street, I can find a safe place to sleep
Other
Can you describe where you sleep?
*
In your opinion, what prevents you from getting housed?
*
Who do you think is responsible for helping you with your homelessness?
*
Nobody, I am responsible
The Federal Government
The BC Government
The City of Vernon
The Church
Non-profit organizations
Businesses
Landlords
My family
Other
Who is responsible?
*
Which organization is helping you with your homelessness?
*
Archway Society for Domestic Peace
Cammy LaFleur Street Clinic
City of Vernon
Downtown Primary Care Center
Interior Health
North Okanagan Community Chaplaincy
Salvation Army House of Hope
Hope Outreach
Turning Points Collaborative
Upper Room Mission
Feed the streets
Other
Which organization?
*
Substance Use
Do you currently use substances to get through your day?
*
Yes
No
Have you used substances in the past?
*
Yes
No
What substances are you using?
*
Alcohol
Marijuana
Prescription medicines, such as pain pills, stimulants, or anxiety pills
Methamphetamine
Cocaine/crack
Opiates
Hallucinogens (LSD)
Heroin
Other
What other substance are you using?
*
Do you want to stop using your substance?
*
Yes
No
Have you tried to stop using your substance in the past?
*
Yes
No
What program have you tried?
*
Abstinence based
Replacement therapy
Other
What program?
Personal Safety
Within the past 30 days, have you been physically assaulted or attacked?
*
Yes
No
Within the past 30 days, have you been robbed?
*
Yes
No
Have you been sexually assaulted within the past 30 days?
*
Yes
No
Do you feel safe at the Upper Room Mission?
*
Not safe at all
Rarely
Sometimes
Usually
All the time
Do you have any suggestions for the Upper Room Mission regarding your personal safety?
*
Food
Is getting enough to eat a problem for you usually, sometimes, rarely or never?
*
Usually
Sometimes
Rarely
Never
Out of the past 30 days, how many days have you eaten?
*
Every day
Most days
Not many days
On average how many meals do you eat daily?
*
1 meal
2 meals
3 meals
Where did you get access to food? (May Select Multiple)
*
Fast food place
Purchased food at a supermarket
Meals at the shelter
Meals at the Upper Room Mission
Meals provided by friends or family
Food found on the street or in garbage cans
Other
Where did you get access to food?
*
Clothing
Over the past 30 days, has obtaining clothes been a problem for you usually, sometimes, rarely or never?
*
Usually
Sometimes
Rarely
Never
Where did you get access to clothing? (Select Multiple)
*
Bought clothes at a retail store
Bought clothes at the Upper Room Mission Boutique Thrift Store
Bought clothes at another thrift store
Received free clothing at the Upper Room Mission
Received free clothing at another service provider
Other
Where did you get access to clothing?
*
How do you feel about the clothing you receive at the Upper Room Mission?
*
Not Satisfied
Rarely Satisfied
Sometimes Satisfied
Usually Satisfied
Mostly Satisfied
Do you have any suggestions for the Upper Room Mission regarding clothing?
*
Hygiene
Now, I like to ask you about your hygiene and well-being. During the past 30 days, has finding a place to wash up, shower or bath been a problem for you?
*
Usually
Sometimes
Rarely
Never
Have you used the Upper Room Mission shower program in the past 30 days?
*
Yes
No
How was your experience with the shower program?
*
Not Satisfied
Rarely Satisfied
Sometimes Satisfied
Usually Satisfied
Mostly Satisfied
Do you have any suggestions for the Upper Room Mission regarding the shower program?
*
Faith in God
Now I like to ask you some questions about the topic of Faith. Do you have faith in God?
*
Yes
No
How do you practice your faith in God?
*
I go to church
I pray
I read the bible
I don't practice my faith
Not happening right now due to my struggles
I don't know, but want to know more
Other
How do you practice faith in God?
*
Are you interested in knowing more about God and your relationship with Him?
*
Yes
No
Upper Room Mission
Do you have any suggestions or advice you would like to share with us that would help the Upper Room Mission provide better services to you and other guests?
*
Submit
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