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Group Session Intake
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Hidden Fields
Group Session ID
Owner ID
Contact ID
Counselor Id
Counseling/Education ID
Service File ID
Disclosure URL
Agency Id
Owner Role/Agency Formula
IsLegacySubmission
TRUE
FALSE
Registration Capacity
Registrations Remaining
Allow Registration?
Agency Logo URL
Agency Email
Agency Phone
Agency Address
Agency Address 2
Agency City
Agency State
Agency Zip
Class Name
This session is full
Unfortunately this session has reached its maximum registration capacity. Please go back and choose a session on a different date.
How did you
hear about us
?
HUD Outreach
Agency Outreach
Another Person
Lender
Another Agency
Real Estate Agent
Other
Attendee
First Name
Last Name
Email
Phone
Phone Type
Please select...
Home
Work
Mobile
Street Address
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Attendee Details & Demographic Information
What is your
birth date
?
You must enter the date in this format: MM/DD/YYYY
Are you living with a
disability
?
Yes
No
What
gender
do you identify as?
Female
Male
Trans female
Trans male
Trans non-binary
Non-binary
Other
What is the highest degree or
level of education
you have completed?
Less than HS Diploma
High school diploma or equivalent
Some post-secondary education
Certification from a vocational or technical training program
Associate's Degree
Bachelor's Degree
Master's or other graduate degree
What is your
race
?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other multiple race
Chose Not to Respond
Are you
Hispanic, Latino or Spanish
origin?
Yes
No
I choose not to respond
Is there
another person from your Household attending
this session?
Yes
No
Second Attendee
First Name
Last Name
Email
Co-applicant Details & Demographics Information
What is the
race of the second attendee
?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other multiple race
Chose Not to Respond
Is the
second attendee
of
Hispanic, Latino or Spanish
origin?
Yes
No
I choose not to respond
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Household & Demographic Information
To demonstrate our commitment to equity and our service reach, we are required to collect demographic information from the clients we serve. Please answer the following demographic questions.
What is your current
household size,
including yourself and the additional applicant, if applicable?
What best describes your
household type
?
Single Adult
Female-headed single parent household
Male-headed single parent household
Married/Domestic Partnership without dependents
Married/Domestic Partnership with dependents
Two or more unrelated adults
Other
What is your current
marital status
?
Single
Married / Domestic Partnership
Separated
Divorced
Widowed
Unknown
Chose Not to Respond
What is your
monthly household income
? (Include income from all sources including employment, child support, social security, pension, etc.)
Annual household income
Housing Information
What is your
current housing
arrangement?
Renting
Owning
Staying with family or friends
Homeless
Staying in a Shelter
Other
Do you live in a
rural area
?
Yes
No
Are you a
first-time homebuyer
(you have not owned a home for the past 3 years)?
Yes
No
Are you a
first-generation homebuyer
(your parents did not own a home)?
Yes
No
Language & Heritage Information
What
language
do you
primarily speak
?
English
Spanish
Somali
Hmong
Karen
Oromo
Amharic
Chinese - Cantonese
Chinese - Mandarin
French
German
Tagalog
Vietnamese
Italian
Korean
Russian
Polish
Arabic
Portuguese
Japanese
French Creole
Greek
Hindi
Persian
Urdu
Gujarati
Armenian
ASL
Cambodian
Czech
Indonesian
Swahili
Turkish
Ukrainian
Other
Chose Not to Respond
Do you need
language assistance
or an interpreter
Yes
No
Were you
born outside of the United States
?
Yes
No
Do you identify with any of the following
immigrant or new American communities
?
No, does not apply
British/U.K.
Burmese (includes Karen and Karenni)
Cambodian
Canadian
Chinese
Dominican
Ethiopian
Filipino
German
Guatemalan
Haitian
Honduran
Hmong
Indian
Kenyan
Korean
Laotian
Liberian
Mexican
Nigerian
Oromo
Russian
Salvadoran
Vietnamese
Somali
Other
Military Information
Are you
active military
?
Yes
No
Are you a
veteran
?
Yes
No