Resource Mapping Questionnaire

Primary services are those listed in your mission statement, or the main effort of your organization/program.

Secondary services are things you offer to clients making use of your primary services, i.e. – childcare during legal appointments at a legal services organization.

Question Title

* 1. Organization Information

Organization Name

Address

City

State

ZIP Code

County

School District

Website

Phone Number

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* 2. Type of Organization

Tribe

Urban Indian Organization

Non-Native Organization

Government Agency

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* 3. Your Information

Name

Position

Email Address

Phone Number

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* 4. Case Management/Advocacy

	Primary	Secondary
Safety Planning and Intake	Safety Planning and Intake Primary	Safety Planning and Intake Secondary
Domestic violence victim advocacy	Domestic violence victim advocacy Primary	Domestic violence victim advocacy Secondary
Sexual assault victim advocacy	Sexual assault victim advocacy Primary	Sexual assault victim advocacy Secondary
CSE/Trafficking victim advocacy	CSE/Trafficking victim advocacy Primary	CSE/Trafficking victim advocacy Secondary
Youth victim advocacy	Youth victim advocacy Primary	Youth victim advocacy Secondary
Homelessness case management	Homelessness case management Primary	Homelessness case management Secondary
Veteran specific case management	Veteran specific case management Primary	Veteran specific case management Secondary
Housing/Systems navigation	Housing/Systems navigation Primary	Housing/Systems navigation Secondary
Document/ID replacement	Document/ID replacement Primary	Document/ID replacement Secondary
Accompany to appointments	Accompany to appointments Primary	Accompany to appointments Secondary
Elder support case management	Elder support case management Primary	Elder support case management Secondary
24-hour hotline	24-hour hotline Primary	24-hour hotline Secondary

Other (please specify)

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* 5. Shelter Services

	Primary	Secondary
Women (18+)	Women (18+) Primary	Women (18+) Secondary
Unaccompanied Youth (12-18)	Unaccompanied Youth (12-18) Primary	Unaccompanied Youth (12-18) Secondary
Men (18+)	Men (18+) Primary	Men (18+) Secondary
Families	Families Primary	Families Secondary
Elders housing	Elders housing Primary	Elders housing Secondary
2SLGBTQIA+ friendly housing	2SLGBTQIA+ friendly housing Primary	2SLGBTQIA+ friendly housing Secondary
Long-Term (30+ days in shelter)	Long-Term (30+ days in shelter) Primary	Long-Term (30+ days in shelter) Secondary
Emergency (24-hour intake)	Emergency (24-hour intake) Primary	Emergency (24-hour intake) Secondary
Transitional housing	Transitional housing Primary	Transitional housing Secondary
Low Barrier (substance abuse)	Low Barrier (substance abuse) Primary	Low Barrier (substance abuse) Secondary
Sober/Clean housing	Sober/Clean housing Primary	Sober/Clean housing Secondary
Pets allowed (excluding service animals)	Pets allowed (excluding service animals) Primary	Pets allowed (excluding service animals) Secondary
Veteran specific housing	Veteran specific housing Primary	Veteran specific housing Secondary
DV/SA/CSE specific	DV/SA/CSE specific Primary	DV/SA/CSE specific Secondary

Other (please specify)

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* 6. If Shelter Provided:

Capacity

Average % full

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* 7. Day Center

	Primary	Secondary
Showers	Showers Primary	Showers Secondary
Laundry	Laundry Primary	Laundry Secondary
PO Box	PO Box Primary	PO Box Secondary

Other (please specify)

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* 8. Housing

	Primary	Secondary
Hotel/Motel Payment	Hotel/Motel Payment Primary	Hotel/Motel Payment Secondary
Rent Assistance	Rent Assistance Primary	Rent Assistance Secondary
Utilities Assistance	Utilities Assistance Primary	Utilities Assistance Secondary
HUD/Section 8/CEU assistance	HUD/Section 8/CEU assistance Primary	HUD/Section 8/CEU assistance Secondary

Other (please specify)

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* 9. Food

	Primary	Secondary
WIC/Food stamp assistance	WIC/Food stamp assistance Primary	WIC/Food stamp assistance Secondary
Food bank	Food bank Primary	Food bank Secondary
Breakfast Service	Breakfast Service Primary	Breakfast Service Secondary
Lunch Service	Lunch Service Primary	Lunch Service Secondary
Dinner Service	Dinner Service Primary	Dinner Service Secondary
Food delivery - Elders/At risk	Food delivery - Elders/At risk Primary	Food delivery - Elders/At risk Secondary
Food delivery - Students	Food delivery - Students Primary	Food delivery - Students Secondary

Other (please specify)

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* 10. Clothing

	Primary	Secondary
Clothing closet	Clothing closet Primary	Clothing closet Secondary
Child clothing	Child clothing Primary	Child clothing Secondary
Personal supplies/hygiene items	Personal supplies/hygiene items Primary	Personal supplies/hygiene items Secondary

Other (please specify)

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* 11. Child Care

	Primary	Secondary
Under 5	Under 5 Primary	Under 5 Secondary
Before/after-school care	Before/after-school care Primary	Before/after-school care Secondary
During appointments	During appointments Primary	During appointments Secondary

Other (please specify)

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* 12. Education

	Primary	Secondary
GED classes	GED classes Primary	GED classes Secondary
ESL classes	ESL classes Primary	ESL classes Secondary
Life Skills training	Life Skills training Primary	Life Skills training Secondary
HS Completion/Credit Retrieval	HS Completion/Credit Retrieval Primary	HS Completion/Credit Retrieval Secondary
College Prep	College Prep Primary	College Prep Secondary

Other (please specify)

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* 13. Employment

	Primary	Secondary
Workforce/job placement	Workforce/job placement Primary	Workforce/job placement Secondary
Certifications	Certifications Primary	Certifications Secondary
Application assistance	Application assistance Primary	Application assistance Secondary
Veteran specific employment	Veteran specific employment Primary	Veteran specific employment Secondary
Unemployment assistance	Unemployment assistance Primary	Unemployment assistance Secondary

Other (please specify)

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* 14. Legal Assistance

	Primary	Secondary
Legal screening	Legal screening Primary	Legal screening Secondary
Obtaining protection orders	Obtaining protection orders Primary	Obtaining protection orders Secondary
Crime Victim assistance	Crime Victim assistance Primary	Crime Victim assistance Secondary
Reunification services	Reunification services Primary	Reunification services Secondary
Restitution assistance	Restitution assistance Primary	Restitution assistance Secondary
Family court/custody	Family court/custody Primary	Family court/custody Secondary
Court advocacy	Court advocacy Primary	Court advocacy Secondary
Felony advocacy	Felony advocacy Primary	Felony advocacy Secondary
Charge vacatur	Charge vacatur Primary	Charge vacatur Secondary
Immigration services	Immigration services Primary	Immigration services Secondary
Child welfare services	Child welfare services Primary	Child welfare services Secondary
Eviction/utility shutoff assistance	Eviction/utility shutoff assistance Primary	Eviction/utility shutoff assistance Secondary

Other (please specify)

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* 15. Medical/Dental

	Primary	Secondary
Low-income medical care	Low-income medical care Primary	Low-income medical care Secondary
Low-income dental care	Low-income dental care Primary	Low-income dental care Secondary
Medicaid/Apple Care application	Medicaid/Apple Care application Primary	Medicaid/Apple Care application Secondary
Medicaid/Apple Care	Medicaid/Apple Care Primary	Medicaid/Apple Care Secondary
Bill payments	Bill payments Primary	Bill payments Secondary
Prescription assistance	Prescription assistance Primary	Prescription assistance Secondary
LGBT specific care	LGBT specific care Primary	LGBT specific care Secondary
Veteran specific care	Veteran specific care Primary	Veteran specific care Secondary
HIV testing/care	HIV testing/care Primary	HIV testing/care Secondary
SAFE/SANE program	SAFE/SANE program Primary	SAFE/SANE program Secondary

Other (please specify)

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* 16. Mental Health

	Primary	Secondary
Low-income mental health treatment	Low-income mental health treatment Primary	Low-income mental health treatment Secondary
Emergency assessments	Emergency assessments Primary	Emergency assessments Secondary
Group counseling	Group counseling Primary	Group counseling Secondary
Individual counseling	Individual counseling Primary	Individual counseling Secondary
Psychiatric care	Psychiatric care Primary	Psychiatric care Secondary
Prescription assistance	Prescription assistance Primary	Prescription assistance Secondary
Peer support (list in "Other")	Peer support (list in "Other") Primary	Peer support (list in "Other") Secondary
In-patient care	In-patient care Primary	In-patient care Secondary
Out-patient care	Out-patient care Primary	Out-patient care Secondary
2SLGBTQIA+ specific care	2SLGBTQIA+ specific care Primary	2SLGBTQIA+ specific care Secondary
Veteran specific care	Veteran specific care Primary	Veteran specific care Secondary

Other (please specify)

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* 17. Substance Abuse

	Primary	Secondary
In-patient treatment facility/rehab	In-patient treatment facility/rehab Primary	In-patient treatment facility/rehab Secondary
Out-patient treatment	Out-patient treatment Primary	Out-patient treatment Secondary
Drug/Alcohol abuse screening	Drug/Alcohol abuse screening Primary	Drug/Alcohol abuse screening Secondary
Medication-Assisted therapy	Medication-Assisted therapy Primary	Medication-Assisted therapy Secondary
Needle exchange/safe injection site	Needle exchange/safe injection site Primary	Needle exchange/safe injection site Secondary
Youth services	Youth services Primary	Youth services Secondary

Other (please specify)

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* 18. Transportation

	Primary	Secondary
Bus vouchers	Bus vouchers Primary	Bus vouchers Secondary
Uber/Lyft/taxi vouchers/payment	Uber/Lyft/taxi vouchers/payment Primary	Uber/Lyft/taxi vouchers/payment Secondary
Case manager transportation	Case manager transportation Primary	Case manager transportation Secondary

Other (please specify)

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* 19. Youth Services

	Primary	Secondary
Foster care/child welfare support	Foster care/child welfare support Primary	Foster care/child welfare support Secondary
Youth cultural programs	Youth cultural programs Primary	Youth cultural programs Secondary
Outdoors programs	Outdoors programs Primary	Outdoors programs Secondary
Tutoring/Homework help	Tutoring/Homework help Primary	Tutoring/Homework help Secondary
Youth legal assistance	Youth legal assistance Primary	Youth legal assistance Secondary
Emancipation assistance	Emancipation assistance Primary	Emancipation assistance Secondary
Youth counseling/psychiatric care	Youth counseling/psychiatric care Primary	Youth counseling/psychiatric care Secondary
Safe space/after school space	Safe space/after school space Primary	Safe space/after school space Secondary
2SLGBTQIA+ programs	2SLGBTQIA+ programs Primary	2SLGBTQIA+ programs Secondary

Other (please specify)

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* 20. Cultural Services

	Primary	Secondary
Cultural services (specify in "Other")	Cultural services (specify in "Other") Primary	Cultural services (specify in "Other") Secondary
Cultural healing/ceremony on site (specify in "Other")	Cultural healing/ceremony on site (specify in "Other") Primary	Cultural healing/ceremony on site (specify in "Other") Secondary
Native-specific services	Native-specific services Primary	Native-specific services Secondary
Required cultural competency for staff (please specify type/frequency in comments)	Required cultural competency for staff (please specify type/frequency in comments) Primary	Required cultural competency for staff (please specify type/frequency in comments) Secondary
Referrals to Tribal/Native organizations for cultural services	Referrals to Tribal/Native organizations for cultural services Primary	Referrals to Tribal/Native organizations for cultural services Secondary

Other (please specify)

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* 21. Training Topics Offered

Topic 1

Topic 2

Topic 3

Audience 1

Audience 2

Audience 3

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* 22. Awareness

	Primary	Secondary
Events	Events Primary	Events Secondary
Campaigns	Campaigns Primary	Campaigns Secondary
Legislative lobbying	Legislative lobbying Primary	Legislative lobbying Secondary
Policy development	Policy development Primary	Policy development Secondary
Coalition building	Coalition building Primary	Coalition building Secondary

Other (please specify)

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* 23. Law Enforcement

	Primary	Secondary
Liaison	Liaison Primary	Liaison Secondary
Victim advocacy	Victim advocacy Primary	Victim advocacy Secondary
Community Outreach	Community Outreach Primary	Community Outreach Secondary
Corrections facility	Corrections facility Primary	Corrections facility Secondary
Youth detention facility	Youth detention facility Primary	Youth detention facility Secondary

Resource Mapping Questionnaire

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* 1. Organization Information

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* 2. Type of Organization

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* 3. Your Information

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* 4. Case Management/Advocacy

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* 5. Shelter Services

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* 6. If Shelter Provided:

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* 7. Day Center

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* 8. Housing

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* 9. Food

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* 10. Clothing

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* 11. Child Care

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* 12. Education

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* 13. Employment

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* 14. Legal Assistance

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* 15. Medical/Dental

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* 16. Mental Health

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* 17. Substance Abuse

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* 18. Transportation

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* 19. Youth Services

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* 20. Cultural Services

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* 21. Training Topics Offered

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* 22. Awareness

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* 23. Law Enforcement

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* 24. Other Services:

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* 25. Anything we missed?