Rent Well Intake Form

INTAKE FORM
This information will be kept confidential. The information collected will only be used for reporting purposes associated with Rent Well.
Name of Student

First NameLast Name
Date:

MonthDayYear
Email
example@example.com
Address

Address Line 1 - Street Address

Address Line 2 (leave blank if not needed)

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Emergency Contact Name
Emergency Contact Phone Number
Format: (000) 000-0000.
Emergency Contact Address

An address where a six-month follow-up is likely to reach you

CityState / Province

Postal / Zip Code
American Indian / Alaska NativeAmerican Indian / Alaska Native & WhiteAmerican Indian / Alaska Native & Black/African AmericanAsianAsian & WhiteBlack / African AmericanBlack / African American & WhiteNative Hawaiian / Other Pacific IslanderWhiteOther
HispanicNon-Hispanic
Date of Birth

MonthDayYear
Date
FemaleMaleNon-BinaryPrefer not to answer
16-2425-3536-5051-6565 and above

Other Characteristics

Rows	Yes	No
Are you a Veteran?
Are you disabled?
Are you or have you ever been on Probation or Parole?

Single ParentSingle IndividualTwo Adults / ChildrenTwo Adults / No ChildrenUnaccompanied YouthGrandparents and childrenExtended Family (living with relatives)
How many people live with you?
Enter number only
How many people in your household are under the age of 18?

Income Level - Include income for you and your household BEFORE taxes

Rows	Check if Income Source	Monthly Gross $
Employment
AFDC/TANF
Child Support
Pension
Unemployment
SSI/SSD
None

Other Income Sources - Include income for you and your household BEFORE taxes

Rows	Specify source	Monthly Gross $
Other
Other
Other

Total Monthly Income (All sources)
Total of all Monthly Income
I rentI am in jail/prisonI am temporarily staying with family/friendsHotel / Motel with voucherI am on the street/in a carI am in a shelterHotel / Motel without a voucherI am in Transitional HousingI own my homeSubstance abuse treatment facilityOther
Rental HousingTransitional HousingHotel / Motel with voucherHotel / Motel without voucherSubstance abuse treatment facilityEmergency ShelterOn the street/in a carPsychiatric FacilityHospitalLiving with family/friendsJail/PrisonOther (please specify)
I have an eviction on my record.I owe money to a Landlord that is past due.I have a criminal history that is making it hard for me to get housing.I have been denied housing because of my credit.I have had no prior rental history or have had a large gap in my rental history.A Landlord I have rented from in the past is giving me a bad reference.Current or past alcohol/drug problems have made it difficult for me to find or keep housing.I do not have money for move-in costs or rent.I am between 16 and 27 years of age and was within the jurisdiction of the juvenile court within the past 10 years.
Friend/FamilyCommunity Agency/Case WorkerHomes for GoodHousing AuthorityHousing Connections WebsiteOther
The information below is being collected for statistical reasons and reported to local and state agencies.
PART II: AGREEMENT OF UNDERSTANDING

To gain a better understanding of how Rent Well can benefit you, please read (or have it read to you) and sign the following agreement. If you have questions, please ask your Instructor before signing.
HOW RENT WELL WORKS / RELEASE OF INFORMATION

By taking Rent Well I understand that:
- I will become educated about my rights and responsibilities as a renter.
- I will learn about affordable housing and the steps to take to overcome screening barriers such as evictions, criminal history and credit problems.
- There will be landlords willing to consider Rent Well graduates, but there is no guarantee or promise a landlord will rent to me. Some landlords use a special screening criteria just for Rent Well graduates.
- Some landlords are willing to consider issues on a case-by-case basis.
- Homes for Good, Laurel Hill Center, and other Agencies teaching Rent Well are not responsible for decisions made by any landlord.
- The program does not offer rent assistance, nor help with security deposits.
- The Rent Well Instructor and staff at Laurel Hill Center are here to help, but are not lawyers and therefore cannot give me legal advice
- I must attend every training session and complete all of the work to earn a Certificate of Completion.
- I must develop and complete the terms of a Personal Contract to earn a Certificate of Completion.
- I will complete a Post Graduation Plan to help me stay focused once the class is over.
- I will submit an “I’ve Rented!” Card to Laurel Hill Center after signing a rental/lease agreement or a “Change of Address” Card when my contact information on my Intake Form changes.
- Laurel Hill Center will contact me to complete an additional Followup Form one year after graduating from Rent Well.
*IMPORTANT NOTE – It is important that you update your contact information given on the Intake Form when it changes. We cannot send a 6 Month Follow-up Form without current information. -Please use the Change of Address Card in your graduation packet or contact your case manager.
Participant Signature
By signing this form, I give my consent for Laurel Hill Center to share the information on this form with WellSky, who will share this information with the State of Oregon and other funding providers. I have read and understand this statement.
Date Signed

MonthDayYear
Date
Should be Empty:

INTAKE FORM

Participant Signature