MAIN FHANC General Intake Form

Fair Housing Intake Form
Are you a landlord?
Please note that we do not provide individual counseling services to landlords. For general information about fair housing and/or our education services, please visit our website at www.fairhousingnorcal.org.

Thank you contacting Fair Housing Advocates of Northern California.

If you are a landlord who would like more information about fair housing, please visit our website at fairhousingnorcal.org. If you would like to request a training or a fair housing presentation for you or your employees, please contact our education department at adriana@fairhousingnorcal.org.

Please review our "Client Disclosure Statement" at fairhousingnorcal.org, which includes expectations for clients when working with a counselor or attorney.

Thank you!

Gracias por contactar a Fair Housing Advocates of Northern California.

Si usted es arrendador y desea obtener más información sobre la igualdad de oportunidades de vivienda, visite nuestro sitio web en fairhousingnorca.org. Si desea solicitar una presentación sobre igualdad de oportunidades de vivienda para usted o sus empleados, comuníquese con nuestro departamento de educación a través de adriana@fairhousingnorcal.org.

Por favor, revise nuestra "Client Disclosure Statement" (Declaración de Divulgación) en fairhousingnorcal.org, que incluye las expectativas para los clientes al trabajar con un consejero o abogado.

¡Gracias!

Are you contacting us regarding a fair housing concern that happened in Marin, Sonoma, Solano, or Napa Counties? ¿Se está comunicando con nosotros en relación con un problema de vivienda justa ocurrido en los condados de Marin, Sonoma, Solano o Napa?

Thank you for contacting Fair Housing Advocates of Northern California. Our office covers Marin, Sonoma, Solano, and Napa Counties. Your matter is outside of our service area.

We encourage you to review our Tenant Information Booklet for more information on fair housing and tenants’ rights. If you believe you have been discriminated against, please contact your local fair housing organization or Community Development Corporation for further assistance. If you have received an eviction notice or have another landlord tenant concern, please contact your local legal aid organization or legal services organization.

Gracias por comunicarse con Vivienda Justa del Norte de California. Nuestra oficina cubre los condados de Marin, Sonoma, Solano y Napa. Su caso queda fuera de nuestra área de servicio.

Le recomendamos consultar nuestro folleto informativo para inquilinos, donde encontrará más información sobre la vivienda justa y sus derechos como inquilinos.

Si considera que ha sido víctima de discriminación, por favor comuníquese con su organización local de vivienda justa o con una corporación de desarrollo comunitario para recibir asistencia adicional. Si ha recibido un aviso de desalojo o tiene alguna otra inquietud sobre su relación con el arrendador, le sugerimos ponerse en contacto con su organización local de asistencia legal.

Please complete this form and an intake counselor will reach out to you
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
SMS Opt-In Disclosure: By providing a telephone number and submitting the form you are consenting to be contacted by SMS text message. Message & data rates may apply. Reply STOP to opt out of further messaging. View our privacy policy https://www.fairhousingnorcal.org/privacy-policy.html.Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Address
Street Address (include unit number)
City
State
5-Digit Zip Code
What is your race?
What is your ethnicity?
What is your gender?
Is anyone in your household age 62 or older?
What is your preferred language?
Are you behind on or struggling to pay your gas or electric bill? Would you like to know about PG&E’s low income energy assistance and medical assistance programs?

Household Members Breakdown

Including yourself, please enter the number of people in your household by category
Number of adult females (18+)
Number of adult males (18+)
Number of minors (under 18)
Total Household Size (auto-calculated)
Does anyone in your household have a mental or physical disability?
Disability Type