SURVIVOR NEEDS ASSESSMENT
Please take a moment to fill out this confidential assessment form
that will allow us to better meet your needs. You may hand-carry it
to a staff member or mail it to the address below:
Survivor Outreach Services
Army Community Service
Bldg. 34N
Picatinny Arsenal, NJ 07806
Full Name: ______
Mailing Address: ______
Phone Number: ______
Email Address: ______
Preferred Method of Contact: q Email q Phone q Text Message q U.S. Mail
Children’s Names and Ages (if applicable): ______
______
Please select the services you would like to see:
q Recognition of the anniversary/yahrzeit and birthday of your Fallen Service Member?
Fallen Service Member (name and rank): ______
Anniversary/Yahrzeit: ______Birthdate: ______
q Workshops on Grief-related topics (e.g. Coping with Holidays, Society’s Grief Time Table, Dating Again)?
q Workshops on Benefits Entitlements (e.g. Social Security Administration)?
q Workshops on Financial Topics (e.g. Insurance, Investing, Mortgages)?
q Social Programs (e.g. Scrapbooking on the Internet, Base Tour w/Humvee Ride)?
q Support Groups (e.g. T.A.P.S. Local Care Group)?
q Organize a Chapter of a group like America Gold Star Moms or Gold Star Wives?
q Programs for children?
q Installation Services (e.g. Morale, Welfare & Recreation, Commissary, Post Exchange)?
q Updated information (Please circle prefered method: newsletter, website, Facebook, Tweets )?
Comments or Additions to the above: ______
______
Please select the services you are currently in need of:
q Airmen & Family Readiness or Fleet Family Support Center Programs – Air Force and Navy equivalent of Army Community Services.
q Army Community Service – Programs offered are: Army Emergency Relief, Army Family Action Plan, Employment Readiness, Family Advocacy, Information & Referral, Relocation Readiness, Sexual Assault.
q Chaplain Services – Worship services and spiritual counseling.
q Child and Youth Programming – Counseling, respite care, childcare, SKIESUnlimited instructional classes, School Liaison Services, playgroups, grief camps and other surviving child activities.
q Family & Morale, Welfare & Recreation – Forge Fitness; Picatinny Golf Course; Information, Tour & Registration; Frog Falls Aquatic Park; Outdoor Recreation; Trailer Park; Guest House.
q Financial Planning – Individual counseling or workshops on budgeting, credit repair, estate planning, financial planning, mortgages, insurance and debt management.
q Legal Services – Wills, power-of-attorney, notary public , etc.
q Long-Term Family Case Management – Service Records and Reports (e.g. citations, LOD).
q Military Benefits – Death Gratuity, Survivor Benefit Plan, DEERS, and TRICARE.
q Support Coordination – Provides educational workshops, social programs and coordinates counseling services.
q VA Benefits – Dependency and Indemnity Compensation (DEIC), Servicemen’s Group Life Insurance (SGLI), Veteran’s Group Life Insurance (VGLI), National Servicemen Life Insurance, VA Home Loan, Improved Pension for Non-Service Connected Death, Burial Expenses and Education Benefits.