CRI Required Demographic Information

CRI Required Demographic Information

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
Email Address:
example@example.com
Phone Number
Format: (000) 000-0000.
Yearly Income:
Employment Status:

Other
Limited English Proficiency Status:
Current Living Situation:

Other
Marital status:

Other
Rural Area Status:
Education Level:
Ethnicity:
Race:
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: