WATCH CDC Intake Form

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One of our 3 case managers will work alongside you, connecting you to community resources and helping you manage your urgent needs.  Due to the number of cases, 
please expect a call/text/email from the Housing Clinic within 1 week.  All cases will be screened for emergency status daily and will be responded to as soon as possible.


For resources related to the following needs, please visit:

Housing, Housing Search, Food, Medical Care


This form is for Waltham residents ONLY


Filled out this form prior
You have indicated that you have filled out this form before. Please fill out our Existing Client Form at https://www.tfaforms.com/4996480

Non-Waltham Residents
You have indicated that you are not a Waltham Resident. Please visit https://www.masshousinginfo.org/. You will be able to find the agency that is best suited to assist you based on your city of residence.

If you are a resident of Newton, Needham, Natick, Weston, or Wellesley, please visit https://www.tfaforms.com/5009325.
Client and Household Information
An email and phone number are required to fill out this form. If you do not have email, please text Gian at (781) 296-8865 or come to WATCH, 24 Crescent Street, Suite 201, Waltham Monday-Friday 10 am to 4pm.



Please enter the name on your ID

Please enter the name on your ID

Please put complete street address and apartment or unit number






For example: 1234567890 (Only Numbers)

i.e. Phone, Text, Email and preferred time of day (if you have one)


i.e. 01/05/1974







Enter your income with no dollar sign, commas, or decimals














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


Housing Information



Enter amount with no dollar sign, commas, or decimals

Enter amount with no dollar sign, commas, or decimals
Housing Problems

What is your housing problem?  Check all that apply

Behind on Rent

Enter a number with no dollar sign, commas, or decimals
School Aged Children
Youth 1




Youth 2




Youth 3




Youth 4




Landlord Information 
In order to best help you, we many need to contact your landlord to explain the rental assistance programs.








i.e. 000-000-0000

Non Housing
Which of these do you need help with?:



Household Finances
In order to match you with available resources, please share information about your financial situation. 
  




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