Community Needs Community Needs Database This form allows residents affected by the sewer crisis to report health, financial, and support needs. Fields marked * are required. Language Is English your first language? * Select Yes No Preferred language Interpreter needed? Select No Yes Accessibility support needed? (select all that apply) Deaf / hard of hearing Sign language interpreter Blind / low vision Other accessibility support Mobility support (select all that apply) Uses wheelchair Limited mobility Requires home visit Other mobility support Your details Full name * Address line * Suburb * Postcode * Email Phone * Preferred contact method * Select Phone Email Text Your needs Needs (select all that apply) * Health Financial Housing Food Transport Mental health Disability support Other Other details Urgency * Select Immediate (today) Within 3 days Within a week Not urgent Details * How badly affected? (1-10) * Select 1 - Minimal impact 2 - Very mild 3 - Mild 4 - Low 5 - Moderate 6 - Significant 7 - Severe 8 - Very severe 9 - Extreme 10 - Crisis level Estimated budget (optional) Household size (number of people) Household age groups (number of people) 0-5 6-12 13-17 18-64 65+ Consent I confirm the information is accurate to the best of my knowledge. * You may contact me about additional support options. Submit
