ULGH Client Intake Form
  • UNIVERSAL INTAKE FORM

  • Welcome!

  • To ensure we have the information we need to best serve you, please take a few moments to fill out the form below. If you have any questions, please feel free to contact us at any time. Thank you!

  • PERSONAL INFORMATION

  • Format: (000) 000-0000.
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  • HOUSEHOLD INFORMATION

  • EMPLOYMENT INFORMATION

  • Format: (000) 000-0000.
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  • Permission to Share

  • I grant permission for information provided during the intake process to be shared within the departments of Urban League as necessary for the purpose of coordinating services, monitoring the quality of services and determining eligibility for services. In addition, for mailing of service/League program information or for contacting me regarding Urban League services. I also grant permission for information to be shared with outside agencies for the sole purpose of providing wrap around services.

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  • Waiver/Release Consent

  • I grant Urban League of Greater Hartford, Inc. permission to record, videotape, and photograph and use information from my personal testimony for the purpose of marketing and promoting the agency. These images may be displayed on any or all of the following entities: Urban League of Greater Hartford website, written materials (newsletters, press releases, annual reports, program booklets, etc.) and social media websites.

    By granting permission to Urban League, I understand that no special compensation will be provided to me for use of my image and that I may not be informed in advance of the specific use of my image.

    Urban League of Greater Hartford staff will maintain confidentiality of participant information as required by federal, state, local statutes or ordinance. By Signing in this section you are granting your permission regarding the two statements listed above: Permission to Share, and Waiver/Release Consent.

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  • Conflict of Interest and Disclosure Statement

  • URBAN LEAGUE OF GREATER HARTFORD prohibits the following actions in order to prevent a conflict of interest in the provision of its youth development, health and wellness, employment, education, housing counseling and financial education services.

    Urban League of Greater Hartford will ensure and monitor that the agency, its staff, or any member of their immediate family must not take any action that may result in, or create the appearance of: administering the housing counseling program for personal or private gain; providing preferential treatment to any organization or person; or undertaking any action that might compromise the agency’s ability to ensure compliance with all funders including HUD program requirements, or to serve the best interests of its clients.

    Individual directors or employees, or family members of the Urban League of Greater Hartford may not accept a fee or any other consideration for referring a client to mortgage lenders, brokers, builders, real estate sales agents, or brokers.

    A director, employee, officer, contractor, or agent of Urban League of Greater Hartford shall not refer clients to outside program or services including; mortgage lenders, brokers, builders, or real estate sales agents in which the officer, employee, director, his or her spouse, child, or general partner has a financial interest, neither may they acquire the client’s property from the trustee in bankruptcy or accept a fee or any other consideration for referring a client to other agencies, mortgage lenders, brokers, builders, or real estate sales agents or brokers.

    A director, employee, officer, contractor, agent, his or her spouse, child, general partner, or organization in which he or she serves as employee (other than with the Urban League of Greater Hartford, or with whom he or she is negotiating future employment, may not have a direct interest in the client as a landlord, broker, or creditor, or originator, have a financial interest in, service, or underwrite a mortgage on the client’s property, own or purchase a property that the client seeks to rent or purchase, or serve as a collection agent for the client’s mortgage lender, landlord, or creditor. I have read and received a copy of the Urban League of Greater Hartford Conflict of Interest Policy Statement.

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  • Disclosure

  • URBAN LEAGUE OF GREATER HARTFORD offers Youth Development, Education, Workforce Development, Health and Wellness and Economic Enrichment programs and services. The Economic Enrichment Center offers HUD one-on-one housing counseling and education services in the following service areas: Pre-purchase Homeownership, Financial Management/Budget, Rental Housing,

    Mortgage Delinquency and Default , and Being an Owner Occupant Landlord of a 2 – 4 Unite Home. Note: information regarding Furthering Affirmatively Fair Housing is included in all housing program service areas. Clients are entitled to receive any or all these services free of charge.

     

    The only financial relationships this agency has is with entities that award program or operations grants. The following is a list of funders that provide financial grants to support the HUD services provided by this agency: Connecticut Housing Finance Authority (CHFA), U. S. Dept. of Housing and Urban Development (HUD), CT Dept. of Housing (DOH), United Way of Central and Northeastern Connecticut, Wells Fargo Bank, Bob’s Discount Furniture, Liberty Bank, Bank of America, National Urban League, and CT Local Initiative Support Corporation (LISC).

     

    Urban League of Greater Hartford is not involved in providing real estate and/or mortgage services and no fee or commission is received for services.

     

    No Client Obligation:

    Clients have no obligation to receive, purchase, or use any product or service offered by this agency or any services of its industry partners or other party in exchange for your receiving HUD housing counseling services.

     

    Alternatives:

    As a condition of this agency’s services, and in alignment with meeting counseling goals, and in compliance with HUD’s Housing Counseling Program requirements, we may provide information on alternative services, programs, and products available to you, if applicable and known by our staff.

     

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  • Privacy Policy

  • URBAN LEAGUE OF GREATER HARTFORD is committed to providing quality services to you and this policy outlines our ongoing obligations to you in respect of how we manage your Personal Information. Our professional ethics require that each employee maintain the highest degree of confidentiality when handling matters. Urban League collects your Personal Information for the primary purpose of providing our services and information and marketing programs and services to our clients. We may also use your Personal Information for secondary purposes closely related to the primary purpose, in circumstances where you would reasonably expect such use or disclosure. You may unsubscribe from our mailing/marketing lists at any time by contacting us in writing. When we collect Personal Information, we will, where appropriate and where possible, explain to you why we are collecting the information and how we plan to use it.

    Types of information that we gather about you
    ·        Information we receive from you orally, on applications or other forms, such as your name, address, social security number, assets, income and other sensitive information.

    ·        Information about your transactions with us, your creditors, or others, such as your account balance, payment history, parties to transactions and credit card usage; and

    ·        Information we receive from a third party to include; credit reporting agency, such as your credit history.

    Sensitive Information
    Sensitive information is defined in the Privacy Act to include information or opinion about such things as an individual's racial or ethnic origin, political opinions, membership of a political association, religious or philosophical beliefs, membership of a trade union or other professional body, criminal record or health information.

    Sensitive information will be used by us only:

    ·        For the primary purpose for which it was obtained

    ·        For a secondary purpose that is directly related to the primary purpose

    ·        With your consent; or where required or authorized by law.

    You may opt-out of certain disclosures
    1)     You have the opportunity to “opt-out” of disclosures of your nonpublic personal information to third parties (such as your creditors), that is, direct us not to make those disclosures.

    2)     If you choose to “opt-out”, we will not be able to answer questions from your creditors. If at any time, you wish to change your decision with regard to your “opt-out”, you may call us at (860) 527-0147.

    Release of your information to third parties
    Where reasonable and practicable to do so, we will collect your Personal Information only from you. However, in some circumstances we may be provided with information by third parties. In such a case we will take reasonable steps to ensure that you are made aware of the information provided to us by the third party.

    1)     So long as you have not opted-out, we may disclose some or all of the information that we collect, as described above, to your creditors or third parties where we have determined that it would be helpful to you, would aid us in counseling you, or is a requirement of grant awards which make our services possible.

    2)     We may also disclose any nonpublic personal information about you or former customers to anyone as permitted by law (e.g., if we are compelled by legal process).

    3)     Within the organization, we restrict access to nonpublic personal information about you to those employees who need to know that information to provide services to you. We maintain physical, electronic and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.

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  • Acknowledge Receipt of Required Documents

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  • URBAN LEAGUE SERVICES AND HOUSING COUNSELING PROGRAM AGREEMENT

  • I give authorization to Urban League of Greater Hartford, HUD, CHFA, DOH and or NFMC program administrators and or their agents to follow-up with me for the purpose of program evaluation or to view documents in my file for evaluation purposes.

    I understand that I may be referred to other housing services of the organization, another agency or agencies that may be able to assist with concerns identified. I understand that I am not obligated to use any of the services offered to me.

     

    Urban League staff and housing counselors may answer questions and provide information, but not give legal advice. In such case I will be referred to the appropriate source for assistance.

    By signing I acknowledge that I have received a copy of Urban League of Greater Hartford Services, Housing Counseling Agreement, Privacy Policy and Disclosures and accept the provisions of all.

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