HOUSING STABILITY RENTAL COUNSELING PROGRAM Intake Form
First Name
Last Name
Email
Current Address
Address Line 1
Address Line 2
City
State
Zip
Home/Cell Phone
Date of Birth
County of Residence:
Preferred Language:
How were you referred to us?
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Race:
American Indian/Alaskan Native
Asian (including the Asian Subcontinent)
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Marital Status:
Single
Married
Divorced
Separated
Other
Gender:
Male
Female
Other/Non-Conforming
Current Housing Arrangement:
Rent
Own
Live Rent-Free
Homeless
Do you live in a rural area?:
Yes
No
Total Household Income:
Total Household Members:
Are you a proficiant English speaker?
Yes
No
Are you currently active military?
Yes
No
Are you a military veteran?
Yes
No
Are you disabled?
Yes
No
Are you the parent or legal guardian of a disabled child or adult?
Yes
No
Highest level of education completed:
Junior High School
High School Diploma or Equivalent
Junior College
College
Graduate School
Other
Credit Report:
Report pulled by agency
Report provided by client
Credit Report
NOTE: Credit Report must be dated within 30 days of this Intake Form!
Reason for housing instability:
Landlord:
Landlord Contact info:
Monthly Rent Payment:
# of Rent Payments Missed:
$ of Rent Payments Missed:
Contact Information