Neighborhood Healing Network Screening Questions: - ULSTL

314-615-3600

1408 N. Kingshighway Blvd. - Saint Louis, Missouri 63113

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Screening Questions:

For each item, indicate if you know someone, witnessed, or were directly impacted by an act of violence within the last 10 years. This information will not be shared with law enforcement. Our only purpose for gathering this information is to provide support services to community residents impacted by violence and crime.

* Indicates required field

Name *

First

Last

Phone Number *

Email *

I know someone who was a victim.
(family, friend, partner, community member)

Assaulted (beat up) *

Yes No

Carjacked *

Yes No

Harmed with a weapon *

Yes No

Car (hit & run) *

Yes No

Hit or threatened by family member *

Yes No

Hit or threatened by partner *

Yes No

Murdered *

Yes No

Shot *

Yes No

Stabbed *

Yes No

Threatened with a gun or knife *

Yes No

I witnessed someone being victimized.
(family, friend, partner, community member)

Assaulted (beat up) *

Yes No

Carjacked *

Yes No

Harmed with a weapon *

Yes No

Car (hit & run) *

Yes No

Hit or threatened by family member *

Yes No

Hit or threatened by partner *

Yes No

Murdered *

Yes No

Shot *

Yes No

Stabbed *

Yes No

Threatened with a gun or knife *

Yes No

I was a victim.
(myself)

Assaulted (beat up) *

Yes No

Carjacked *

Yes No

Harmed with a weapon *

Yes No

Car (hit & run) *

Yes No

Hit or threatened by family member *

Yes No

Hit or threatened by partner *

Yes No

Murdered *

Yes No

Shot *

Yes No

Stabbed *

Yes No

Threatened with a gun or knife *

Yes No

Submit

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