Client Intake Form
Please complete so we can best assist you.
Type of Service
*
Please Select
Pre-Purchase
Post-Purchase
Rental Counseling
Homeless Assistance
Home Retention
Name
*
First Name
Last Name
Date of Birth
*
Age
*
Gender
*
Please Select
Female
Male
Prefer not to answer
Gender Non-Conforming
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Phone Number
*
Please enter a valid phone number.
Secondary Contact
Please enter a valid phone number.
Email
*
example@example.com
Preferred Contact Method
*
Please Select
E-Mail
Phone Call
SMS Text
Languages Spoken
*
Please Select
English
French
Spanish
Other
Client Referred By
Please Select
HUD Outreach
Agency Outreach
Another Person
Lender
Another Agency
Real Estate Agent
Other
N/A
Rural Area Status
*
Please Select
Lives in a rural area
Does not live in a rural area
Chose not to respond
Limited English Proficiency Status
*
Please Select
Limited English Proficient
Not Limited English Proficient
Chose Not To Respond
Head of Household
*
Please Select
Single Adult
Female Headed Single Parent
Male Headed Single Parent
Married Without Dependents
Married With Dependents
Two or More Unrelated Adults
Other
Education Level
Please Select
Less Than High School
High School Diploma or Equivalent
Some College, No Degree
Post Secondary Non-Degree Award
Associate's Degree
Bachelor's Degree
Master's Degree
Doctoral or Professional Degree
Ethnicity/Race
*
Please Select
American Indian/Alaskan Native
American Indian/Alaskan Native & Black
American Indian/Alaskan Native & White
Asian
Asian & White
Black/African American
Black/African American & White
Choose Not To Respond
Native Hawaiian or Pacific Islander
Other
White
Hispanic/Latin
*
Please Select
Choose Not To Respond
Is Hispanic
Not Hispanic
Marital Status
Please Select
Divorced
Married
Prefer Not To Answer
Domestic Partners
Separated
Single
Widowed
Primary Language
*
Please Select
English
Spanish
Other
Employment Status
Please Select
Working Full-Time
Working Part-Time
Unemployed
Retired
Self-Employed
Student
Prefer not to answer
Employer Name
Number of Dependents
*
Number in Household
*
Housing Status
*
Please Select
Own
Rent
Other
Annual Income
*
$15,000-$25,000
$25,000-$40,000
$40,000-$60,000
$60,000+
How Did You Hear About Us
Please Select
Attorney/Legal
Other/Misc
Creditor
Advertisement
Friend
Social Media
Lender
Is there a Co-Applicant?
*
Please Select
Yes
No
Please have Co-Applicant complete a separate intake application.
Co-Applicant Name if Applicable
First Name
Last Name
Submit
Should be Empty: