Housing Navigation Intake Form

Housing Navigation Intake Form
This intake form is to request housing navigation counseling in Marin, Sonoma, Solano or Napa counties.

Note that FHANC does not own or operate any housing and does not provide housing placement. FHANC also does not provide eviction defense services. If you received an eviction notice, please contact your local legal aid or legal services organization.

Click "Next" to complete the intake form.

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.
Preferred contact method
Date of Birth

MonthDayYear
Date
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?
How did you hear about us?
Are you at risk for losing your housing? If yes, when?
What is your current housing situation?
Caller Type (Salesforce)

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
What is your annual household income?
Example: $75,000.00 should be entered as 75000
What is your main source of income?
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?
Do you have a rental subsidy or voucher?

Household Members Breakdown