CRI Participant Intake Form

CRI Participant Intake Form

As a 501c3 non-profit corporation and HUD certified housing counseling agency, CRI is required to track demographic information from each participant entering our program. Please confidentially complete the following fields.
Your Name:

First NameLast Name
Birth Date:

MonthDayYear
Gender:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address From Date:

MonthDayYear
Address To Date:

MonthDayYear
Email Address:
example@example.com
Phone Number:
Format: (000) 000-0000.
Preferred Contact Method:
National ID:
Spouse First and Last Name:
How Heard:
Yearly Income:
Employment Status:

Other
Limited English Proficiency Status:
Current Living Situation:

Other
Marital Status:
Housing Status:

Other
Rural Area Status:
No. Dependents:
No. in Household:
Employment Status:
Employer Name:
Months at Job
Education Level:
Hispanic/Latin:
Race:
Tribal Affiliation:
Primary Language:
Military Status:
Education:
How do you identify? (Check all that apply)
Referral Source:

Other
Referred by:
What's your reason for contacting us?
Specific program(s) or service(s) that you're interested in?
What would you like to speak with us about?

Other
Any comments or questions?
Should be Empty: