Guest Survey

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? *

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? *

Other causes *

Where do you sleep? *

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? *

Who is responsible? *

Which organization is helping you with your homelessness? *

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? *

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? *

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) *

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? *

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? *

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? *

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? *