Form Center

2. Family Resource Center Community Needs Assessment
   Franklin County Family Resource Center
   P. O. Box 188
   Rocky Mount, VA 24151
   Phone 540-483-5088
   24 Hour Hotline 540-483-1234
   Please take a moment to answer the following questions to assist us with our Community Needs Assessment.
4. Gender

   1. Male
   2. Female
   3. N/A
5. Age Group
   -- Select One --15 - 1718 - 2526 - 3940 - 5455 - 6970 - 99
6. Which Franklin County District do you live in?
   -- Select One --BooneBlackwaterBlue RidgeGills CreekRocky MountSnow CreekUnion Hall
8. How did you hear of our services? (Check all that apply)

   1. Phone
   2. Internet
   3. Law Enforcement
   4. Hospital
   5. Family/Friend
   6. Church

   1. PCS
   2. STEP
   3. Social Services
   4. Doctor
   5. Lawyer
   6. Other
9. If Other, please list
11. Have you ever been in an abusive relationship?

    1. Yes
    2. No
12. If you have been in an abusive relationship, check all options that kept you from leaving the relationship.

    1. Safety Plan
    2. Food
    3. Money
    4. Housing
    5. Health Care

    1. Social Services
    2. Counseling
    3. School
    4. Drug Rehab
    5. Other
14. If you answered Other to the previous question, please list reason.
16. Have you ever known someone that was in an abusive relationship?

    1. Yes
    2. No
17. If you have known someone that was in an abusive relationship, check all options that kept them from leaving the relationship.

    1. Safety Plan
    2. Food
    3. Money
    4. Housing
    5. Health Care

    1. Social Services
    2. Counseling
    3. School
    4. Drug Rehab
    5. Other
19. If you answered Other to the previous question, please list reason.
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