General Housing Clinic Sign-Up Form

Street

Email

Preferred Contact Method

CellSecondaryEmailText

Date of Birth

Total # of adults in household

Do you need a translator?

YesNo

What bedroom-size apartment are you seeking?

Over the last 2 weeks, how often have you been bothered by problems related to housing or financial difficulties?

0 - Not at all1 - Several days2 - Over half of the days3 - Nearly every day

Is this your first time requesting help from Metro West CD?

YesNo

Please pick your in-person session date