Connective Storm Needs Assessment - Registry

Impacted by the recent storm?

Please fill out this 5 minute survey to share your needs with local non-profits. 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 new resources as they become available

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:

Household Members

Does anyone in the household self-identify as having a disability?

YesNo

Are any household members aged 65 years or older?

YesNo

Is there a veteran or active duty service member living in the household?

YesNo

Consent & Release

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. Your information will not be used for any purpose other than targeting local resources to you.

Disclosures:

You will receive up to 10 text messages/month from Connective related to COVID-19, 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

Connective works in collaboration with other community-based nonprofit organizations to help residents in our community recovery. May we share your information with other nonprofit organizations involved in disaster recovery efforts?

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

Would you like us to share your information with local government entities responding to disasters in your area? This information would be used to coordinate response efforts and to advocate for more resources for our community. If you are uncomfortable with us sharing individual level data with government entities, please respond no, in which case, we will only do so with nonprofit agencies (if you selected 'Yes' on the previous consent statement).

YesNo

Next Survey

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

YesNo

Contact Information

Single-family home	Apartment	Mobile home
Duplex/fourplex	Condo	Townhome