Client Intake Form
The Junction Coalition 419 Junction Ave. Toledo, OH 43607
Note:
If you you have an impairment, disability, language barrier, or otherwise require an alternative means of completing this form or accessing information about housing counseling, please talk to your housing counselor about arranging alternative accommodations.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When is the best time to reach you?
Please indicate your gender
Male
Female
Non-binary
Prefer Not to Say
Ethnicity
Hispanic
Non-Hispanic
Race
Indian/Alaskan Native
Asian
African-American
Native Hawaiian/Pacific Islander
Caucasian/White
Biracial or Multiracial
How did you find out about us?
Word of mouth
Member of Staff
Website search
Social media
Bank or Mortgage servicer
Family/Friend
Religious or Social Org
HUD
Other
Are you disabled?
Yes
No
Are you a Veteran?
Yes
No
Are you a U.S. Citizen?
Yes
No
Marital Status
Single
Divorced
Married
Widowed
Separated
Household Size
Estimated Household Income (Gross)
Do you own your home?
Yes
No
Do you have housing insurance?
Yes
No
Submit
Should be Empty: