Housing and Assistance Intake Form Housing and Assistance New FormFull Legal NameEmailPhone/MobileAddressCityStateZip CodeCountrySelect CountryUnited States (US)Preferred Method of Contact Call Text/WhatsApp EmailSelect Service- Select -Rental CounselingHomeownership EducationHousing Stabilization Services (HSS)General AssistanceLegal ReferralRefugee Support Brief Description of Your Situation:Rental CounselingCurrent Housing Situation?- Select -RentingLiving with familyHomelessOther (Please Specify)Please SpecifyDo you have a lease? Yes NoFacing eviction or rent increase? Yes NoMonthly Rent?What is your rental concern?Homeownership EducationAre you a first-time homebuyer? Yes NoHave you been pre-approved for a mortgage? Yes NoEstimated monthly income?Areas you're considering buying in?What do you hope to gain from this workshop?Housing Stabilization Services (HSS)Do you currently have a housing case manager? Yes NoDo you have a verified disability or health condition? Yes NoWhat kind of assistance are you seeking through HSS?General AssistanceWhat type of general help are you looking for? Financial Assistance Utility Help Case Management Food Support Clothing or Shelter Others (Please Specify)Please Specify:Describe your situationLegal ReferralType of Legal Concern Housing/Eviction Immigration Domestic Violence Custody/Family Law Other (Please Specify)Please Specify:Is this urgent? Yes NoBrief Description?Refugee SupportCountry of OriginDate of Arrival in U.S. Language Assistance Needed? Yes NoPreferred Language?What type of support do you need? Housing Health Insurance Employment School Registration Legal Assistance Others (Please Specify)Please Specify:Demographics:Race: (Select One) American Indian/ Alaskan Native Asian Black or African American Native Hawaiian or other pacific Islanders White American Indian/ Alaskan Native & White American Indian/ Alaskan Native & Black Asian & White Black or African American & White Native Hawaiian/ Other pacific Islanders & Black Other Race (Please Specify)How did you hear about us? Mailer, Flyer, or Brochure Newspaper Agency Friend or Relative Internet Realtor Someone who took a workshop Lender/ Mortgage Co OtherIf others, Specify:If others, Specify:Have you received similar services before? Yes NoIf yes, please note the type and length of services:Add Additional Individual:Would you like to add another person? Yes NoEnter Full Name of PersonPhone/MobileEmail I consent to have this website store my submitted information so they can respond to my inquirySubmit Form
